BIM + HEALTHCARE:

Utilization of BIM in the Design of a Primary Healthcare Project

Jennifer R. Chellappa

December 2009

Submitted towards the fulfilment of the requirements for the Doctor of Architecture

degree.

School of Architecture

University of Hawaiʻi

DArch Project Committee

Hyoung-June Park, Chairperson

Randall Akiona

Walter Muraoka

Aaron Wagner

BIM + HEALTHCARE:

Utilization of BIM in the Design of a Primary Healthcare Project

Jennifer R. Chellappa

December 2009

We certify that we have read this Doctorate Project and

that, in our opinion, it is satisfactory in scope and

quality in partial fulfilment for the degree of Doctorate

of Architecture in the School of Architecture, University

of Hawaiʻi at Mānoa.

DArch Project Committee

______________________________________________________ Hyoung-June Park, Chairperson

______________________________________________________ Randall Akiona

______________________________________________________ Walter Muraoka

______________________________________________________ Aaron Wagner

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ACKNOWLEDGEMENTS

It is with deepest gratitude that I would like to thank Professor

Hyoung-June Park for all his guidance and support through this research

project. I am witness to his dedication and integrity as an educator for the

pursuit of architecture.

I would also like to thank with great appreciation, Professor Randy

Akiona, for his honest and valuable advice during this academic pursuit. In

the midst of researching he has been supportive and brought clarity during

times it was much needed.

Much thanks goes to Walter Muraoka for sharing his sound knowledge

and advice pertaining to my topic. I really appreciate his level of

professionalism and knowledge in the field of healthcare design. Additionally,

I thank him for the encouragement, kindness and time he has made in

participating on this project with me.

Aaron Wagner – no words can really describe my gratitude; an

enormous thank you to him for all his patience, time and willingness to advice

and support in investigating this topic of Building Information Modeling. I

am obliged by his generosity, leadership and intelligence he has shared with

me during this academic pursuit.

Thank you to my family, my parents Paul and Emily Chellappa, who

from thousands of miles away, are always sending me love, support and

constant prayers. Thank you to my brother, Steven and my sister Sarah for

listening and encouraging me. Last but surely not least, Robert Guinn, my

fiancé. Thank you Rob for all you honest and sound advice, encouragement,

patience and love.

“Lord, you are faithful to lead me on.”

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TABLE OF CONTENTS

Acknowledgements ................................................................................................................... iii

List of Figures ........................................................................................................................... vi

Abstract ...................................................................................................................................... 1

1. Introduction ............................................................................................................................ 2

1.1. Project statement ............................................................................................................. 2

1.2. A brief history on process-oriented BIM ........................................................................ 3

1.3. Origins of healthcare design ........................................................................................... 5

1.4. Summary ......................................................................................................................... 9

2. Problem Statement ............................................................................................................... 11

2.1. Need for BIM in Healthcare ......................................................................................... 11

2.2. Summary ....................................................................................................................... 13

3. Scope of Research ................................................................................................................ 14

3.1. BIM + Healthcare ......................................................................................................... 14

3.2. Environment of patients and caregivers ........................................................................ 15

3.2.1. Patient Safety Issues .............................................................................................. 15

3.2.2. Other patient outcomes .......................................................................................... 18

3.2.3. Staff Outcomes ....................................................................................................... 22

3.3. Healthcare modules using BIM ..................................................................................... 25

3.4. Managing tools, equipment, and other details .............................................................. 26

3.5. Summary ....................................................................................................................... 28

4. BIM Strategies ..................................................................................................................... 29

4.1. Phasing .......................................................................................................................... 30

4.2. Prototyping .................................................................................................................... 32

4.3. Baseline Model ............................................................................................................. 33

4.4. Summary ....................................................................................................................... 34

5. Case study ............................................................................................................................ 35

5.1 Program .......................................................................................................................... 35

5.2 Summary ........................................................................................................................ 38

6. Design Models ..................................................................................................................... 41

6.1 Phasing: temporary barriers and egress routes ............................................................... 41

6.1.1. Monitoring temporary barriers ............................................................................... 48

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6.1.2. Managing temporary egress routes during renovation ........................................... 52

6.2 Prototyping: Rules and Integration ................................................................................ 54

6.2.1. Rules – setup BIM prototype parameters ............................................................... 57

6.2.1.1. Rules - General Examination Room prototype…………………………........…67

6.2.1.2. Rules - Pharmacy prototype....………………………………………………...…69

6.2.2. Integration – utilizing BIM prototypes into design projects .................................. 74

6.2.2.1. Integration - General Examination Room prototype…………………………..74

6.2.2.2. Integration - Pharmacy prototype……………………………………………..…76

6.3 Baseline model: continuity through bim ........................................................................ 78

6.3.1. Continuity and sharing of BIM model ................................................................... 79

6.3.2. Continuity and sharing of BIM data information ................................................... 82

6.4 Summary ........................................................................................................................ 83

7. Outcomes ............................................................................................................................. 85

8. Discussion ............................................................................................................................ 92

9. Glossary ............................................................................................................................... 96

10. Bibliography ...................................................................................................................... 98

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LIST OF FIGURES

Figure 1 Typical CAD outputs & typical BIM outputs. .............................................................. 5

Figure 2 Richard Foque illustrates the traditional, linear process of design which is

irreversible in time. .................................................................................................................... 8

Figure 3 Richard Foque – four important domains for the design of a primary healthcare

facility. ....................................................................................................................................... 8

Figure 4 Diagram depicting aspects in the nature of healthcare. ............................................ 11

Figure 5 BIM contributes solid data to further Evidence-based design. ................................. 14

Figure 6 Table Summarizing General outcomes of EBD. ........................................................ 25

Figure 7 Diagram showing healthcare modules isolated for independent inquiry or new

developments. ........................................................................................................................... 26

Figure 8 Full scale mock-up & BIM simulation of patient room. ............................................ 27

Figure 9 Overview diagram of forecasting/proceeding through BIM phasing. ....................... 30

Figure 10 Diagram depicting iterations of BIM prototyping. .................................................. 33

Figure 11 Comparison between digital representation and BIM baseline model. ................... 34

Figure 12 Images of the case study for the renovation of a primary healthcare facility. ........ 35

Figure 13 2D CAD existing design. ......................................................................................... 38

Figure 14 2D site plan.............................................................................................................. 39

Figure 15 Scanned 2D topographic site plan. .......................................................................... 39

Figure 16 Developing design using a traditional approach. ................................................... 40

Figure 17 Changes during design process. .............................................................................. 40

Figure 18 The case study project adopted into a BIM process had one new construction phase

and four remaining renovation phases. ................................................................................... 41

Figure 19 Existing phase. ......................................................................................................... 43

Figure 20 Phase 1 – new construction. ................................................................................... 43

Figure 21 Phase 2 – demolition. .............................................................................................. 44

Figure 22 Phase 2 – temporary barriers. ................................................................................. 44

Figure 23 Phase 2 – continued demolition. .............................................................................. 45

Figure 24 Phase 2 – new construction. .................................................................................... 45

Figure 25 Phase 3 – demolition. .............................................................................................. 46

Figure 26 Phase 3 – new construction. .................................................................................... 46

Figure 27 Phase 4 – demolition. .............................................................................................. 47

Figure 28 Phase 4 – new construction. .................................................................................... 47

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Figure 29 Phasing scheduled tasks communicate status and capacity of production by

comparison of planned and actual outcomes. .......................................................................... 49

Figure 30 Phasing Pharmacy space relationship to example Laboratory CFD modeling

analysis. ................................................................................................................................... 51

Figure 31 BIM coordination of egress routes along with schedules. ....................................... 52

Figure 32 Establishing temporary egress routes during renovation. Coordinated and

visualizing the egress routes according to phases. .................................................................. 53

Figure 33 BIM Strategy: Prototyping. ..................................................................................... 55

Figure 34 General Examination Room Prototype. ................................................................... 56

Figure 35 Pharmacy Prototype. ............................................................................................... 56

Figure 36 list from Guidelines for Design and Construction of Health Care Facilities 2006. 57

Figure 37 Parameters selected for prototypes based on the relationship to the healthcare

guidelines. ................................................................................................................................ 58

Figure 38 Arranging and setting parameters for Desired Area for the exam room prototype.60

Figure 39 Components from Revit City can be downloaded for this exam room prototype. ... 62

Figure 40 Components utilized for starting an exam room prototype. .................................... 64

Figure 41 Creating parameters to reflect necessary clearances for the exam room prototype.

................................................................................................................................................. 65

Figure 42 Unique parameters set in healthcare prototypes are supported by calculated data

conveyed in schedules. ............................................................................................................. 67

Figure 43 Parameters inspired by healthcare guidelines used for a General Examination

Room Prototype. ...................................................................................................................... 69

Figure 44 Observation Room prototype is developed from General Examination Room

Prototype. ................................................................................................................................. 70

Figure 45 Pharmacy prototype is based initially on the dimensions of the 2D template. ........ 71

Figure 46 Typically manual referencing of information between 2D template into Revit. ...... 72

Figure 47 Pharmacy equipment – Ducted laminar flow fume cupboard component. .............. 72

Figure 48 Pharmacy prototype. ............................................................................................... 73

Figure 49 Integrating General Examination room prototype and Pharmacy prototype into a

design project. .......................................................................................................................... 74

Figure 50 Integrating and using prototypes in a design project. ............................................. 76

Figure 51 Integrating a Pharmacy prototype into a design project. ........................................ 77

Figure 52 Integrated Pharmacy prototype. .............................................................................. 78

Figure 53 Example of applying baseline modeling by exporting BIM model into other BIM

application tools. ..................................................................................................................... 80

Figure 54 Baseline model of a BIM prototype for a typical patient room. .............................. 81

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Figure 55 Baseline model of a BIM prototype for a typical patient room. .............................. 82

Figure 56 BIM modeling in Revit. ............................................................................................ 85

Figure 57 BIM modeling in Revit of lighting details and GIS imported topographic form. .... 86

Figure 58 BIM modeling in Revit of prototype grouped and scheduling on a sheet. ............... 86

Figure 59 BIM model coordinated from Revit to Navisworks information management system

................................................................................................................................................. 87

Figure 60 Detailed items of BIM identified with detailed coordinated scheduling. ................ 88

Figure 61 BIM model coordinated from Revit to Autodesk Design Review information sharing

system. ...................................................................................................................................... 89

Figure 62 BIM model in Design Review – detailed objects inquiry ......................................... 90

Figure 63 BIM model within Design Review marked-up for review. ....................................... 90

Figure 64 BIM model coordinated from Revit to MS Access database system. ....................... 91

Figure 65 Diagram of combined BIM strategies. .................................................................... 94

1

ABSTRACT

Currently Building Information Modeling (BIM) is at the forefront of the

building industry. The process of BIM involves building industry professionals and

client users groups using available 3D applications and other digital media for

synchronized and continuous data sharing. The BIM process includes all cooperative

actions among these professionals in a design project. In contrast to a traditional

design process in using 2D representative CAD applications, BIM supports 3D design

and modeling with correlated information identifying object properties, calculated

data and other detailed information.

While useful for various building types the definitive nature of healthcare

design benefits from the BIM process largely in comparison to other building types.

Healthcare design focuses on the development of a healing environment.

Investigation of the environment of healthcare facilities reveals some level of

evidence concerning the affect of atmosphere on the wellness of patients, caregivers

and other user groups. At this time, the available credible reports supporting evidence

for improving the healing environment is developing. Implementing BIM for

healthcare projects is a liaison in the pursuit of Evidence-based design (EBD). The

availability of solid data contributes to EBD in reaching an ideal for designing

healthcare facilities. Exploring the relationship between the BIM process and the

nature of Healthcare design reveals connections between the sharing of information

and the gathering of information as a large contributor for the pursuit of healing

environments, leading to overall advancements in healthcare design.

For this research, a case study of a design for a healthcare facility project is

reviewed in its traditional process. Adopting the design project with application of a

BIM process of design, rather than the traditional process, establishes a level of

comparison highlighting the results of BIM in healthcare design. With regards to

critical aspects in the nature of healthcare BIM strategies are utilized for the

investigation of the case study project. In this document BIM is employed with a

couple of detailed studies for phasing the design process of the healthcare project,

creating modeling prototypes, and making reference to a baseline model in order to

increase the overall success of the healthcare design project.

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1. INTRODUCTION

In this section the project statement is introduced. Additionally, the history

and development regarding Building Information Modeling and healthcare design are

addressed providing the ideas which led up to the investigation of this project.

1.1. PROJECT STATEMENT

Building Information Modeling (BIM) is cooperative actions between building

industry professionals and client user groups, all using available 3D applications and

other digital media for simultaneous and consistent data sharing in an on-going design

project.1 2 3 BIM provides the capabilities of interfacing and correlating multiple

layers of various kinds of information. The categories of information are 1) visual

representation, which is the information consisting of object properties and object-

oriented graphic components database entries, 2) calculated information which

includes specifications, costs and drawings schedules and 3) documentation of

relationships and responsibilities consisting of contracts, warranties, maintenance

information, etc.4 Ideally, BIM would be fully integrated among all professions with

various collaborative projects having a functional information processing linked to

one another. While BIM has been applied to various building types, the methods used

are not fully developed for healthcare projects. In the case of healthcare design

projects, utilizing BIM is an efficient process which supports the coordination of

multiple variables found in healthcare facilities. Furthermore, the collected data from

credible research, evaluations and evidence gathered from the operations of the

patients, doctors, clients and other partakers of the health facility become critical

1 Chuck Eastman et al., BIM handbook: a guide to building information modeling for owners, managers, designers, engineers, and contractors (Hoboken, NJ: Wiley, John & Sons, Inc., 2008). 2 H.J. Park, “BIM + Evolution: The Utilization of Building Information Modeling at an Early Design Stage” (paper presented at the University of Hawaii at Manoa, School of Architecture, Honolulu, Hawaii, 2007). 3 Filiz Ozel, “Building Information Modeling for Healthcare Facilities” (Microsoft PowerPoint, Arizona State University - College of Design, May 19, 2008). 4 Matthew Kennedy, “Great Expectations: BIM for Healthcare,” The Samborn Report (Dimensions Newsletter), no. Summer 2008, http://www.ssoe.com/news/article2.aspx.

3

factors to make design decisions. This type of design method has been developed as

“Evidence-Based Design (EBD).”5 Since Roger Ulrich pioneered the study of EBD

in 1984 with his paper, “View through a window may influence recovery from

surgery,” EBD has become prevalent in healthcare design. 6 Weill Greenberg Center

in New York7 is recognized for the exemplary use of EBD. In this paper, issues

regarding healthcare facilities are presented and various strategies of using BIM are

explored based on the specific nature of healthcare through a case study of a primary

healthcare facility renovation.

1.2. A BRIEF HISTORY ON PROCESS-ORIENTED BIM

Currently, BIM has become increasingly prevalent in the building industry.

However new BIM may seem, according to Eastman, the concepts, approaches and

methods we now recognizes as BIM have been identified approximately 30 years ago

with the earliest documented example identified as “Building Description System” – a

working prototype published by the AIA Journal, by Charles Eastman, then later at

Carnegie-Mellon University, in 1975. Since then, the research and development of

this concept produced different terminologies carrying the same definition and were

used through the years in different countries. Consolidating the terminology to a

more recent English term of “Building Modeling” – in the sense that “Building

Information Modeling is used today – initially appeared, in 1986, in the title of a

paper written by Robert Aish. His paper includes 3D modeling, automatic drawing

extraction, intelligent parametric components, relational databases, temporal phasing

of construction processes and so forth. Shortly after the current use of the English

5 Robert Anthony, “Definition of Evidence-Based Design for Healthcare,” The Center for Health Design, 2009, http://www.healthdesign.org/aboutus/mission/EBD_definition.php. 6 Roger Ulrich, “View through a window may influence recovery from surgery,” Science, April 27, 1984. 7 Chris Gaerig, ed., “Weill Greenberg Center New York, New York Polshek Partnership Architects/Ballinger,” Healthcare Design, 2008.

4

term, “Building Information Model” appeared December of 1992 in a paper,

Automation in Construction by authors G.A. van Nederveen and F. Tolman.8

Prior to the BIM, the history or architectural documentation was exercised

through drawings representing a building. Regardless of whether the drawings are

physically or digitally produced, they make up an annotated booklet of instructions

for constructing a building. These drawings containing plans, sections and elevations

are composed of skillfully drafted lines, where each line is a part of a larger

abstraction meant to communicate design intent. In times of antiquity, the master

builder had responsibilities of managing these documents as both architect and

builder. Later buildings increased in complexity and the response was specializations

in the design and construction process emerged. Leading from this an exponential

increase in the complexity of buildings from the industrial revolution until our current

day has brought documentation sets spanning all disciplines and professions resulting

in hundreds of drawings shared among several people.

While today we no longer rely on pen and paper to produce drawings and

computer technology (computer-aided design, also known as CAD) has become the

replacement, drawings are still largely generated with a traditional design process

among separate disciplines, in 2D, non-intelligent, lines and text.9 Contrasting the

traditional process of design, illustrated in Figure 1, BIM offers a new process of

communicating the information, roles and responsibilities necessary for the design

and construction of a building.

8 Chuck Eastman et al., BIM handbook: a guide to building information modeling for owners, managers, designers, engineers, and contractors (Hoboken, NJ: Wiley, John & Sons, Inc., 2008). 9 Ibid.

5

Figure 1 Typical CAD outputs & typical BIM outputs.10

BIM is process-oriented, rather than separate disciplines creating drawings

with little or no intelligent connections between each other, assembling all

information in to one location and cross linking the data among associated objects.11

1.3. ORIGINS OF HEALTHCARE DESIGN

Before any standard had become established for healthcare or its facilities,

healing was sought out through culture or religion. Healing had yet to be connected

to scientific research. Due to religious/cultural viewpoints, health was observed and

understood based on those perspectives. In the 19th century advances in chemistry

and laboratory techniques and equipment led into what we now call modern medicine.

It is with this development of medicine and technology, religious views for healing

having become confronted with the scientific evidences of medicine.12 As for the

affects of healing based on environment, in 1860, Florence Nightingale was very

observant and her notes are the earliest documentation recognized for researching the

affects of the environment on a people’s health conditions. Her Notes on Nursing

reveals her observations that “suffering associated with disease is most often not from

10 Greg Demchak, Tatjana Dzambazova, and Eddy Krygiel, Introducing Revit Architecture 2009: BIM for Beginners, 2nd ed. (Indianapolis, Indiana: Wiley Publishing, Inc., 2008). 11 Greg Demchak, Tatjana Dzambazova, and Eddy Krygiel, Introducing Revit Architecture 2009: BIM for Beginners, 2nd ed. (Indianapolis, Indiana: Wiley Publishing, Inc., 2008). 12 Sir William Osler, “The Evolution of Modern Medicine,” Electronic Text Center, 1997.

6

the disease itself but from the lack of basic human comforts such as fresh air, light,

warmth, quiet, cleanliness and nutrition.” 13 It wasn’t until much later formal research

based on this concept began. Apart from a healing environment, research in medicine

continued to fruition. By the time the 20th century rolled around scientific research

has been leading the development of healing and healthcare. In 1972, this practice of

advancing medicine through a systematic scientific method of research became

increasing acceptable because of a Scottish epidemiologist named Professor Archie

Cochrane who wrote a book called Effectiveness and Efficiency: Random Reflections

on Health Services.14 Then the term, “Evidence-based medicine” (EBM) first

appeared in a paper written by Gordon Guyatt et al. called Evidence-Based Medicine:

A New Approach to Teaching the Practice of Medicine. According to Sackett et al.,

Evidence-based medicine (EBM) is formally defined as “the conscientious, explicit,

and judicious use of current best evidence in making decisions about the care of

individual patients.” The practice of evidence based medicine means integrating

individual clinical expertise with the best available external clinical evidence from

systematic research.”15 Since the development of medicine concepts originally

recognized by Nightingale back in 1860 were instinctively resurfaced as concerns

during the early years of hospital buildings.

Healthcare design is the result of cumulative perspectives on providing basic

human needs, methods of caring and curing infirmities, and pursuing healing

environments. Neil Kellman wrote his paper, History of Healthcare Environments

based on these issues and he addresses the effect of modern architecture on the

practices for seeking health and healing. He writes, “Many aesthetics born of the

modern architecture movement can be seen in today’s hospitals: the clean, sterile

lines, lack of ornamentation, and so forth. Over a period of 50 or 60 years, many of

these aesthetic standards have come to be accepted as the way hospitals ought to

be....Unconsciously, people began to realize that the places they were going for their

13 Linda McAllister, “Who Was Florence Nightingale and Why Is She Important Today?,” Children's Health System, 2007, http://magnet.chsys.org/default.aspx?id=102.

14 Archibald Cochrane, Effectiveness and efficiency: random reflections on health services (London: Royal Society of Medicine, Press, 2004), http://www.worldcat.org/oclc/248148013. 15 David Sackett et al., “Evidence based medicine: what it is and what it isn't,” BMJ Journals 1996, no. 312, Editorials (January 13,): 71-72.

7

healthcare were not meeting a host of needs beyond the actual procedures rendered.”

The value people are searching for in healthcare is to be treated as a human in every

aspect; acknowledging the worth of the individual patient. Since then, these needs

have become recognized through the advancements in medical knowledge,

developments in healthcare technology and awareness concerning the importance of

the healing environment. Stemming from Evidence-based medicine brought the

process of basing decisions relative to the built environment on credible research to

achieve the best possible outcomes known as “Evidence-based design” thereby

linking the search for healing to our environment. Nightingale’s concepts were

formalized during this time. Later with Roger Ulrich’s ground-breaking efforts to

pursue further investigation on these concepts, beginning in 1984, evidence-based

design has become ubiquitous among the healthcare design industry.16

Since this realization, healthcare design has engaged various domains of

information recognized as strongholds for facilitating a building that promotes

wellness. The advancements of these domains have brought the healthcare industry

and designing for healthcare to levels of great complexity. The amount of

information necessary to evaluate for the design of a healthcare building has expanded

exponentially since the early hospital facilities that emerged around the 1920s.17

Following traditional methods of architectural design, Richard Foque, an

architect specializing in health buildings, believes that ‘the starting point...is an

interdisciplinary approach based on a holistic perception of man and environment.’

During a lecture given at the Royal Institute of British Architects in May 1999 Foque

reiterated the traditional and linear process of design over the span of time, shown in

Figure 2. From this he explains the development of design from abstract to concrete

and then illustrates this process in relationship to the domains of information involved

in designing for healthcare.18

16 Roger Ulrich, “View through a window may influence recovery from surgery,” Science, April 27, 1984. 17 Neil Kellman, “History of Health Care Environments,” Journal of Healthcare Design: Proceedings from the First Symposium on Healthcare Design 1 (1988): 19-27. 18 Ibid.

8

Figure 2 Richard Foque illustrates the traditional, linear process of design which is irreversible in time.19

His diagrams reflect when separate areas of information fall into the traditional

process of design (Figure 3). The domains of information demonstrate the growth of

research and development in important aspects of healthcare and how these are

managed throughout the duration of a design project.

Figure 3 Richard Foque – four important domains for the design of a primary healthcare facility.20

19 Geoffrey Purves, Healthy living centres: a guide to primary health care design (Oxford: Architectural Press, 2002). 20 Geoffrey Purves, Healthy living centres: a guide to primary health care design (Oxford: Architectural Press, 2002).

9

Currently, healthcare design is the measure of planning for basic human needs,

methods of caring and curing infirmities, and pursuing healing environments using a

traditional process of design used among the building industry. Since the movement

of Evidence-based design, beginning with Roger Ulrich, research and development of

credible information regarding the healthcare environment has increased largely in the

last 25 years. Managing the expanse of information required to design for a

healthcare facility continues to reach new levels of complexity with the advancements

in medical knowledge and technology. In healthcare, good design acknowledges the

worth of the individual, looks to scientific evidence to find technical excellence in

machinery and to a biological basis for caring design. Designing for healthcare also

reflects on past results to find confidence that beauty still exist in the field of

healthcare design.21

1.4. SUMMARY

The full integration of BIM among all professions is the ideal. So that a range

of collaborative projects would have fully functional information processing linked to

one another. While the concept of BIM and its advantages are recognized and the

BIM ideal is projected in every extent of the building industry, the pursuit for BIM

implementation has been attempted on several projects of various building types

successfully. Some of these building types are including commercial, residential,

civic, educational, performance and sports complex buildings such as, the Hillwood

Commercial Project in Dallas, Erie on the Park residential tower in Chicago, the San

Francisco Federal Building, Cooper Union for the Advancement of Science and Art

New Academic building, the Opera Theatre, Sydney Opera House, and the Beijing

National Swimming Centre. Initially BIM has been used for other building types

aside from healthcare facilities. Since the development of BIM, the previous methods

of application have been attempted in healthcare design. However this does not fulfill

full implementation of BIM into healthcare design.

21 Neil Kellman, “History of Health Care Environments,” Journal of Healthcare Design: Proceedings from the First Symposium on Healthcare Design 1 (1988): 19-27.

10

In regards to healthcare design, Evidence-based design (EBD) stems from

Evidence-based medicine (EBM). A concern from this according to Stankos and

Schwarz is,

“Can the theoretical base and methods that are used in medical

research be ‘borrowed’ by the design field?....EBM is anchored in

theoretical knowledge rooted in medical research that is

undertaken with the explicit purpose of answering a question or

solving a problem, but at the same time aims to test, evaluate and

improve the research process employed.”22

Stankos and Swartz claim EBD is locked into a knowledge base which hardly

contains theoretical explanation and so cannot be used to understand the outcomes of

design solutions.

“Thus, EBD should be used carefully in healthcare design, and caution should be used

in the generalization of evidence from a limited number of credible research studies.

This is why a basic systematic review of the existing and future studies is essential.

This kind of meta-analysis will enable designers to choose the appropriate type of

evidence from research to improve the accuracy of predictions in environmental

design.” 23

This D. Arch project investigates BIM in healthcare design. Healthcare design

requires an alternative method in order to achieve full BIM implementation. The

productivity and efficient information sharing of the BIM enhance the maximum use

of EBD in a primary healthcare project. A realistic representation of space

consistently manifested based on the current information is the ideal for making the

most calculative design decisions. The full implementation of BIM in healthcare

design will reap further growth in the healthcare knowledge base and thereby endorse

evidence-based design.

22 Mary Stankos and Benyamin Schwarz, “Evidence-Based Design in Healthcare: A Theoretical Dilemma,” Interdisciplinary Design and Research e-Journal 1, no. 1, Design and Health (January 2007): 1-15. 23 Ibid.

11

2. PROBLEM STATEMENT

2.1. NEED FOR BIM IN HEALTHCARE

Healthcare design has a direct and intentional purpose to ally with healthcare

professionals for promoting wellness. The consistency of the goals and repetitive

activities that occur within the building, leads to regular processing of information.24

BIM will support and permit advances in healthcare as a library of information

relative to the building. In light of this, BIM also influences the quality of EBD.

Healthcare design benefits from BIM because even with multiple layers of design data

BIM guides a healthcare design direction toward promoting wellness effectively. The

critical nature of healthcare, diagramed in Figure 4, corresponds to the methods of

diagnosing/treating patients, providing functional space and housing tools and

equipment.

Figure 4 Diagram depicting aspects in the nature of healthcare.

1) Treating patients includes discussions, examinations, operations, and/or checking

results. According to Princeton’s WordNet – a lexical database of English,

24 Filiz Ozel, “Building Information Modeling for Healthcare Facilities” (Microsoft PowerPoint, Arizona State University - College of Design, May 19, 2008).

12

“treatment” is the “care provided to improve a situation.” Treating patients revolve

around the initial actions when a patient first arrives to a healthcare facility and any

actions that may follow as a result of the patient’s condition.25 Miscommunication

and delay in productivity occur from the consultation between healthcare professional

and patient, or administrative reasons such as form-filling, note-taking, and the

clerical errors like missing appointments or medical records.26 2) Providing the

functional space for healthcare professionals is another essential part in healthcare.

The spaces for these departments are shaped differently based on activity, equipment

and other specific needs. It is vital to have well designed, functional environment.

For example poorly designed, overcrowded patient care areas were found to be a large

contributing factor to nurses feeling frustration, leading to increased human error in

patient treatment, negative attitudes; overall resulting in unsafe healthcare practice.

This is completely against the main purpose of the healthcare profession so it is vital

to have well designed, functional environment.27 3) Housing the sophisticated tools

and equipment also has a significant role in the nature of healthcare. Designing for

healthcare equipment is vital because healthcare is so dependent on these

sophisticated tools for diagnosis and readings’ results. The difficulty comes with

space designed rigidly to one piece of equipment when technology advances and

redesigning for updated equipment or new equipment is required. Designing with

anticipation of future developments in healthcare technology remains to be an issue.28

Among all the facets involved in the healthcare profession, designing for it can be

challenging. Additionally, attempting to pursue EBD for various different issues

involved in the healthcare environment is challenging with the plethora of detailed

25H.R.H. Patel et al., “Outpatient clinic: where is the delay?,” Journal of the Royal Society of Medicine 95, no. December 2002 (2002): 604-605. 26 Ibid. 27 Matthew Carmona, Sarah Carmona, and Wendy Clarke, A Bibliography of Design Value for The Commission for Architecture and the Built Environment (London: University College London - The Bartlett School of Planning, 3, 2003), http://www.cabe.org.uk/files/a-bibliography-of-design-value.pdf. 28 Orlando Maione, ed., “Open Building: A New Paradigm in Hospital Architecture,” AIA Academy Journal (October 27, 2004), http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_openbuilding_102704&dspl=1&article=article.

13

information and variables affecting the entire environment. These issues make

healthcare design more challenging.

2.2. SUMMARY

The nature on which healthcare design is based upon, BIM is a compatible

process of design. The process of BIM provides accessibility to solid data

information which is applicable to EBD explorations. Thus, BIM advances the

effectiveness of healthcare design as a whole.

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3. SCOPE OF RESEARCH

3.1. BIM + HEALTHCARE

BIM has the capacity to amalgamate a bridge between the healing

environment and the services of the healthcare professionals. As a tool for evidence-

based design, BIM is employed as a liaison between patient outcome data and specific

building conditions and locations. Figure 5 illustrates the concept of various types of

information managed through the BIM process and serving as reliable data

contributing to further development of EBD.

Figure 5 BIM contributes solid data to further Evidence-based design.

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3.2. ENVIRONMENT OF PATIENTS AND CAREGIVERS

A few Healthcare challenges centre on maintaining environmental control for

patient safety in areas such as air quality, energy control, noise factor, communication

and infection control. Solutions are developed by adapting healing patterns which are

achieved by monitoring quality of design which can be done so by establishing

parameters under BIM tools.29 Also, administered by a hospital’s facilities

management department, a BIM model can be the reference library for all product and

equipment information enabling the creation of maintenance schedules, standards

manuals, and purchase orders.30

In order to use BIM has a connection between patient outcome data and the

environment; the outcomes established thus far through EBD provide a starting point

for understanding the environment of patients and caregivers. These suggested

solutions developed from EBD serve as a foundation for developing the parameters

under BIM tools. Referencing the Literature Review on Evidence-Based Healthcare

Design, three general outcomes of EBD relate to 1) patient safety issues such as

infections, medical errors and falls, 2) other patient outcomes relating to pain, sleep,

depression, length of stay, spatial orientation, privacy, communication, social support

and overall patient satisfaction and 3) staff outcomes such as injuries, stress, work

effectiveness and satisfaction. Due to repetition in the outcomes of research, a part 4)

summarizes these finding of EBD. Understanding these generalized outcomes of

EBD is important for establishing a foundation for applying the BIM process.31

3.2.1. Patient Safety Issues

Patient Safety is the first section of the review which shows general outcomes

in areas such as infections, medical errors and falls. According to documentation for

29 Filiz Ozel, “Building Information Modeling for Healthcare Facilities” (Microsoft PowerPoint, Arizona State University - College of Design, May 19, 2008). 30 Matthew Kennedy, “Great Expectations: BIM for Healthcare,” The Samborn Report (Dimensions Newsletter), no. Summer 2008, http://www.ssoe.com/news/article2.aspx. 31 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 3.

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EBD, the design of the physical environment can impact nosocomial (hospital-

acquired) infection rates by affecting three major transmission routes – air, contact

and water.32 With a large amount of documentation for EBD the review strongly

supports the following measures for controlling and preventing infections:

• Use effective air quality control measures during construction and renovation to

prevent the outbreak of airborne infections. Measures include, for example, using

portable high-efficiency particulate air (HEPA) filters, installing barriers between

patient-care areas and construction/renovation areas, generating negative air pressure

for construction/renovation areas relative to patient-care areas, and sealing patient

windows.

• Install alcohol-based hand-rub dispensers at the bedside and in other accessible

locations to increase hand-washing compliance and reduce contact transmission of

infection.

• Select easy-to-clean floor, wall, and furniture coverings, and employ proper cleaning

and disinfection procedures.

• Design and maintain the water system at the proper temperature and adequate

pressure; minimize stagnation and back flow; eliminate dead-end pipes; regularly

clean point-of-use fixtures; and consider the location of decorative fountains and

carefully maintain them to minimize the risk of waterborne infection.

• Provide single-bed rooms with private toilets to enable separation or isolation of

patients on admission, so that those with unrecognized infections can be tested and

identified without being mixed in with uninflected individuals in multibed rooms; to

reduce airborne infection transmission by increasing isolation capacity and facilitating

the maintenance of good air quality through measures such as effective ventilation,

filtration, and appropriate air flow direction and pressure (positive or negative); and to

facilitate thorough cleaning after a patient leaves, including the use of

32 Ibid., 4.

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decontamination methods such as hydrogen peroxide vapor (HPV), which may be

much more effective than conventional cleaning.33

Designing for patient safety also takes into account the outcomes based on

medical errors. Based on limited EBD literature medical errors are caused by both the

mistakes of individuals and also a combination of people and the environment.

Factors relating to medical errors include noise, light, and acuity-adaptable, single-

patient rooms. The limited literature available reveals evidence of error rates

increasing sharply when there is an interruption or distraction from an unpredicted

noise.34 Poor lighting levels can affect the performance of healthcare workers and

lead to these medical errors.35 Additionally, verified by pragmatic studies the use of

acuity-adaptable rooms reduces possible sources of medical error such as in transfers,

delays, communication discontinuities among staff, loss of information, and changes

in computers or systems which in turn lowers the error rates.36

Thirdly, designing to prevent falls is part of designing for the overall safety of

patients. There is a significant amount of documentation that examines the causes and

risks factors involved with patient falls in hospitals. Designing for patient safety

against falls is important because those who fall incur physical injuries and adverse

psychological effects and have greater lengths of stay in a hospital.37 Interestingly,

the role of the environment in causing or preventing patient falls is accepted among

many. There is no certain evidence linking environmental interventions with reduced

falls. Studies were made in attempt to identify the design issues that may have

contributed to falls such as the placement of doorways, handrails, toilets, etc. but none

have made comparisons between different design options to determine the

33 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 5. 34 E. A. Flynn et al., “Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy,” American Journal of Health Systems Pharmacy 56, no. 13 (1999): 1319-1325; U. A. Kistner et al., “Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacy,” American Journal of Hospital Pharmacy 51, no. 22 (1994): 2793-2797. 35 T. L. Buchanan et al., “Illumination and errors in dispensing,” American Journal of Hospital Pharmacy 48, no. 10 (1991): 2137-2145. 36 A. Hendrich, J. Fay, and A. Sorrells, “Courage to heal: Comprehensive cardiac critical care,” Healthcare Design, 2002. 37 S. Brandis, “A collaborative occupational therapy and nursing approach to falls prevention in hospital inpatients,” Journal of Quality in Clinical Practice 19, no. 4 (1999): 215-221.

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independent impact of a single design factor on the frequency of falls. At this point,

more research and more rigorous studies are needed to confirm any findings and

which can identify variables involved with the cause or prevention of patient falls.38

3.2.2. Other patient outcomes

General results of EBD are other patient outcomes which include pain, sleep,

depression, length of stay, spatial orientation, privacy, communication, social support

and overall patient satisfaction.

Unfortunately pain is a persistent and severe problem in hospitals. Although

the growing scientific evidence has revealed that exposing patients to nature in true

and various other forms can produce substantial and clinically important alleviation of

pain, which is very encouraging.39 Some research also suggests that patients

experience less pain when exposed to higher levels of daylight in contrast to lower

levels of daylight in their hospital rooms. So designing with large windows affording

views of nature for patient rooms, or procedure spaces, treatment rooms, waiting areas

will aid in the reduction of pain patients may be suffering through.40 Various forms of

conveying nature, whether it is in artwork, visual and auditory simulations of nature

divert or capture the attention of a patient and thereby are effective in relieving some

pain. Theories and research imply patients should not be placed in spaces which lack

nature distractions and which contain other stressors such as noise because this can

38 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 21. 39 S. Malenbaum et al., “Pain in its environmental context: Implications for designing environments to enhance pain control,” Pain 134 (2008): 241-244; R. S. Ulrich et al., “The environment’s impact on stress,” in Improving healthcare with better building design, ed. S. Marberry (Chicago: Health Administration Press, 2006), 37-61; R. Ulrich, “Biophilic theory and research for health design,” in Biophilic design: Theory, science and practice, ed. S. Kellert, J. Heerwagen, and M. Mador (New York: John Wiley, 2008). 40 R. Ulrich, “Biophilic theory and research for health design,” in Biophilic design: Theory, science and practice, ed. S. Kellert, J. Heerwagen, and M. Mador (New York: John Wiley, 2008).

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exacerbate pain.41 Planning for nature views should be pursues in all aspects

including site planning and orientation of a building.42

Designing for improving patient sleep is very important since there is an

increased need for sleep due to the patient illness. Often while a patient is

hospitalized they suffer from poor sleep which significantly hinders their ability to

heal.43 Evidence confirms that this common problem in hospitals can be improved

upon by designing for single-bed rooms which reduces noise disturbance from

roommates, visitors and healthcare staff.44 Also, installing high-performance sound-

absorbing materials to reduce extreme sound conditions will improve sleep.45

Additionally, patient rooms should be oriented and designed to receive natural

daylight. This helps the patient retain normal circadian rhythms.46 All of these design

considerations help patient sleep and in turn help improve their ability to heal.

Several design suggestions for improving other patient outcomes are helping

to also reduce the stress level outcome of patients, such as real or simulated nature

views, gardens, art (more so of art depicting nature rather than abstract art which

research shows can cause stressful reactions). Designing for the reduction of noise

level according to similar methods mentioned for improving patient sleep are applied

41 S. Malenbaum et al., “Pain in its environmental context: Implications for designing environments to enhance pain control,” Pain 134 (2008): 241-244. 42 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 23. 43 Ibid., 24 44 M. T. Southwell and G. Wistow, “Sleep in hospitals at night—Are patients’ needs being met?,” Journal of Advanced Nursing 46, no. 2 (1995): 1101-1109; A. M. Yinnon et al., “Quality of sleep in the medical department,” British Journal of Clinical Practice 46, no. 2 (1992): 88-91. 45 S. Berg, “Impact of reduced reverberation time on sound induced arousals during sleep,” Sleep 24, no. 3 (2001): 289-292; I. Hagerman et al., “Influence of intensive coronary care acoustics on the quality of care and physiological state of patients,” International Journal of Cardiology 98, no. 2 (2005): 267-270; M. K. Philbin and L. Gray, “Changing levels of quiet in an intensive care nursery,” Journal of Perinatology 22, no. 6 (2002): 455-460. 46 A. BaHammam, “Sleep in acute care units,” Sleep and Breathing 10, no. 1 (2006): 6-15; T. Wakamura and H. Tokura, “Influence of bright light during daytime on sleep parameters in hospitalized elderly patients,” Journal of Physiological Anthropology and Applied Human Science 20, no. 6 (2001): 345-351.

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here as well. Creating much quieter environments during construction or renovation

to a building is a high priority.47

Again, similarly to other general patient outcomes, depression can be reduced

by designing for the allowance of daylight. Evidence shows that bright artificial light

or daylight is effective in reducing depression and improving mood. According to

Ulrich, “The evidence that patients’ depression is diminished by daylight exposure

implies the importance of the orientation and site planning of healthcare buildings.”48

Design should ensure patients have more than enough daylight by means of larger

windows or in the case sufficient daylight is not available consider bright artificial

light.49

As for outcomes relating to the length of stay of patients there is very limited

research regarding this issue. There are a few strong studies which regularly identify

positive impact on patients by designing for both light and nature views. However,

further research and testing on a broader range of patient types is necessary to confirm

the current findings.50

According to Ulrich et al, “Wayfinding problems in hospitals are costly and

stressful and have a particular impact on outpatients and visitors, who are often

unfamiliar with the hospital and are otherwise stressed and disoriented.” There is a

large amount of research on wayfinding through hospitals and other complex

buildings but there is minimal research on the performance of different wayfinding

systems or how a wayfinding system may impact other healthcare outcomes.51

Hospitals should integrate wayfinding systems that include coordinated elements such

as visible and easy-to-understand signs and numbers; clear and consistent verbal

47 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 28. 48 R. S. Ulrich et al., “The environment’s impact on stress,” in Improving healthcare with better building design, ed. S. Marberry (Chicago: Health Administration Press, 2006), 37-61. 49 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 33. 50 Ibid., 34. 51 Ibid., 35-36.

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directions along with clear and consistent paper, mail-out, and electronic information;

and a legible physical setting.52

Very little documentation for EBD exists for the issue of improving patient

privacy and confidentiality. This is an important issue recognized and protected by

the U.S. law through the Health Insurance Portability and Accountability Act

(HIPAA). Not enough privacy can lower patient satisfaction. Also patient outcomes

can worsen if patients withhold personal information or refuse to be examined due to

privacy concerns.53 Some design approaches which address this issue is by provision

of single-bed rooms which increases privacy and confidentiality,54 installing hard-wall

partitions to provide speech privacy55 and also extending these hard-wall partitions to

the support ceiling or deck. Another approach is putting in high-performance sound-

absorbing ceiling tiles56 and even designing to include private discussion rooms close

to waiting, admission and reception areas.57 These design approaches help to support

speech privacy; how well a private conversation can be overheard by and unintended

listener.

Improving communication with patients and family members can provide

social support and can help facilitate family members’ involvement in patient care and

increase patient satisfaction with care.58 Again studies reveal that providing single-

52 Ibid., 36. 53 D. Barlas et al., “Comparison of the auditory and visual privacy of emergency department treatment areas with curtains versus those with solid walls,” Annals of Emergency Medicine 38, no. 2 (2001): 135-139. 54 Press Ganey, Inc. “National satisfaction data for 2003 comparing patients with versus without a roommate,” Provided by Press Ganey, Inc. 55 D. Barlas et al., “Comparison of the auditory and visual privacy of emergency department treatment areas with curtains versus those with solid walls,” Annals of Emergency Medicine 38, no. 2 (2001): 135-139; J. Karro, A. W. Dent, and S. Farish, “Patient perceptions of privacy infringements in an emergency department,” Emergency Medicine Australasia: EMA 17, no. 2 (2005): 117-123; E. J. Mlinek and J. Pierce, “Confidentiality and privacy breaches in a university hospital emergency department,” Academic Emergency Medicine 4, no. 12 (1997): 1142-1146. 56 I. Hagerman et al., “Influence of intensive coronary care acoustics on the quality of care and physiological state of patients,” International Journal of Cardiology 98, no. 2 (2005): 267-270; M. K. Philbin and L. Gray, “Changing levels of quiet in an intensive care nursery,” Journal of Perinatology 22, no. 6 (2002): 455-460. 57 A. Joseph and R. Ulrich, “Sound control for improved outcomes in healthcare settings,” The Center for Health Design January, no. 4 (2007). 58Laitinen and Isola, “Promoting participation of informal caregivers in the hospital care of the elderly patient: Informal caregivers’ perceptions,” Journal of Advanced Nursing 23, no. 5

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patient rooms and private discussion areas support communication59 and only some

studies show the use of dim lighting rather than bright lighting in counseling rooms

achieve better result in counseling sessions.60 Aside from this further research is

needed to explore the environment-communication relationship in various healthcare

settings along with how design measures can enhance communication.61

Overall patient satisfaction is predictable with environmental satisfaction in

healthcare settings.62 Based on evidence the needs of the patients and family

members should be a priority when designing for healthcare spaces, providing a

comfortable and aesthetically pleasing environment. This can be achieved by use of

color, artwork, and so forth. Design should also include window views of nature,

appropriate lighting or sunlight and information guides. Single patient rooms for a

number of patient outcomes can provide features such as quietness, privacy,

accessibility to a bathroom which creates a sense of control and thereby contributing

to the overall satisfaction of the patients’ healthcare experience.63

3.2.3. Staff Outcomes

A third section that addresses general outcomes of EBD is staff outcomes.

Staff outcomes included items such as injuries, stress, work effectiveness and

satisfaction.

Occupational injury is not uncommon to staff workers in a healthcare facility.

Studies have been done evaluating the physical stress and strain due to patient

(1996): 942-947; Press Ganey, Inc., “Hospital pulse report: Patient perspectives on American health care,” 2007, http://www.pressganey.com/galleries/default-file/Hospital_Pulse_Report_2009.pdf. 59 P. Astedt-Kurki et al., “Interaction between adult patients’ family members and nursing staff on a hospital ward,” Scandinavian Journal of Caring Sciences 15, no. 2 (2001): 142-150; D. O. Kaldenburg, “the influence of having a roommate on patient satisfaction” (Press Ganey Satisfaction Monitor, 1999). 60 Y. Miwa and K. Hanyu, “The effects of interior design on communication and impressions of a counselor in a counseling room,” Environment and Behavior 38, no. 4 (2006): 484-502. 61 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 36. 62 P. B. Harris et al., “A place to heal: Environmental sources of satisfaction among hospital patients,” Journal of Applied Social Psychology 32, no. 6 (2002): 1276-1299. 63 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 43.

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handling. One design consideration that has been recognized for reducing the

frequency of injury and cost of injury claims of hospital workers in including ceiling

lifts into the design. While the studies have shown reduction in injuries or cost of

injuries it is critical to have a comprehensive lifting program along with the ceiling

lifts. It is still a challenge to isolate the effects of the lifts alone in recent studies

because of a combination of lifts involved in the studies and cultural change in the

hospital settings.64

Healthcare providers experience a high level of work stress, just like patients

experiencing less stress by the reduction of noise, or use of bright lighting or being

placed in single-bed patient rooms. Staff workers also experience less stress. Using

high-performance, sound-absorbing materials to reduce noise levels, administering

bright lights for night staff65 and designing for single-bed patient rooms66 have all

been identified in studies to reduce the stress of hospital workers as well.

As for designing to increase staff effectiveness, relevant studies are still

limited. According to Ulrich et al., “Jobs by nurses, physicians, and other healthcare

workers often require a complex choreography of direct patient care, critical

communications, charting, accessing technology and information and other tasks.”67

Some physical environmental involvements that have shown some affect on staff

effectiveness relates to unit configuration, noise, lighting and other types of

distractions. Further research is still necessary to further understand how the

environment affects staff effectiveness.68

Overall staff satisfaction is mostly is influenced by nonphysical conditions

relating to autonomy,69 compensation70 and performance.71 However the physical

64 Ibid., 45. 65 Ibid., 47. 66 D. D. Harris et al., “The impact of single family room design on patients and caregivers: Executive summary,” Journal of Perinatology 26 (2006): s38-s48. 67 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 49. 68 Ibid. 69 K. O’Rourke et al., “Job satisfaction among nursing staff in a military health care facility,” Military Medicine 165, no. 10 (2000): 757-761. 70 M. F. Best and N. E. Thurston, “Canadian public health nurses’ job satisfaction,” Public Health Nursing 23, no. 3 (2006): 250-255.

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environment can either support or worsen working conditions which affects the stress

level of the workers. Not many studies have examined the effects of environmental

factors in relationship to job-satisfaction. Natural light is the only area where some

studies have touched on this topic.72

3.2.4. Overview of general outcomes of EBD

Overall, there is a strong presence of design approaches involving single-bed

rooms, accessibility to daylight, views of nature, areas zoned for family and visitors,

the possible use of carpeting, using noise-reducing materials, installing ceiling lifts,

configuring layouts specific to hospital staff, etc. Presently, there is some

accumulation of scientific studies which support these positive outcomes due to EBD.

However, to strengthen the role of EBD in positively impacting the healthcare

environment there needs to be further studies on different isolated factors involved in

a healthcare setting. The growth of EBD is dependent on solid information gathered

and evaluated to support design ideas for improving the healthcare environment.

Observing the established outcomes (Figure 6) from EBD provides a foundation and

starting point for using BIM to support investigations to further the credible studies of

EBD.

71 M. K. Douglas et al., “The work of auxiliary nurses in Mexico: Stressors, satisfiers and coping strategies,” International Journal of Nursing Studies 33, no. 5 (1996): 495-505. 72 Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” 52.

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Figure 6 Table Summarizing General outcomes of EBD.73

3.3. HEALTHCARE MODULES USING BIM

Once BIM is able to network facilities data with financial analysis of the

hospital services, BIM has the potential to be used as a powerful tool for strategic

planning.74 A healthcare module is an assembly of organized components, based on

healthcare department needs, contained together and maintaining an independent

nature.75 Each department becomes a module integrated into BIM which contains

specific combinations of building components needed for the specialize activities.

The decomposition of BIM modules entails breaking down the hierarchy of groups,

prototypes, components and further if necessary to objects and artifacts for isolated

73 Roger Ulrich et al., “A Review of the Research Literature on Evidence-Based Healthcare Design,” Healthcare Leadership, no. 5, Evidence-Based Design Resources for Healthcare Executives (September 2008): 53. 74 Matthew Kennedy, “Great Expectations: BIM for Healthcare,” The Samborn Report (Dimensions Newsletter), no. Summer 2008, http://www.ssoe.com/news/article2.aspx. 75 George Miller et al., “Princeton University WordNet,” lexical database, Princeton University WordNet, 2009, http://wordnet.princeton.edu/.

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inquiry of design or redesign. The decomposition is based upon the teamwork of the

components. Observing Figure 7 diagrams the possibilities for detaching information

with the decomposition may pertain to further development or replacement of new

and/or advanced information. Based on isolating the modules future development can

be focused on independent areas of a healthcare facility, avoiding disruption or

distraction relative to other spaces and supports scenario testing on various scales.

Illicit investigations can be performed resulting in relevant information to the

healthcare module. Instead of the current method of seeking researched knowledge

in hopes of validating a design approach, BIM would reveal all sorts of correlations of

the modules and provide the evidence to facilitate long term controlled studies of a

given design project.76 77

Figure 7 Diagram showing healthcare modules isolated for independent inquiry or new developments.

3.4. MANAGING TOOLS, EQUIPMENT, AND OTHER DETAILS

Currently BIM has opened up opportunity to make collaboration more

effective with providing real-time data exchanges, which are detailed scheduling,

geometric coordination of healthcare equipment along with Mechanical, Electrical &

Plumbing (MEP), and providing an explicit library of information for future strategic

76 Heng Li et al., “Integrating design and construction through virtual prototyping,” Automation in Construction , Elsevier 17, no. 8 (11, 2008): 915-922. 77 Matthew Kennedy, “Great Expectations: BIM for Healthcare,” The Samborn Report (Dimensions Newsletter), no. Summer 2008, http://www.ssoe.com/news/article2.aspx.

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planning.78 Risks and/or desired outcomes involved with managing the coordination

of required equipment and tools and so forth are consolidates under the BIM process

of design allowing preventative and assisting actions to be placed accordingly.

BIM used for the special characteristics of healthcare design also include

accurate facility as-built information which can be critical to future renovations. BIM

potentially reduces the need for full scale mock ups of patient rooms, surgical suites,

etc. BIM is a repository of initial information provided by the client such as site

information, area requirements and so forth which supports scenario testing for

clients.79 Creating a realistic scenario using BIM offers hard data information. This is

useful for calculation and analysis to further develop healthy environments. Rather

than creating a static full scale mock up, a much more flexible and transportable full

scale virtual reality experience can be arranged by means of simulation provided

through BIM.80 81 A comparison is depicted in Figure 8 below.

Figure 8 Full scale mock-up82 & BIM simulation of patient room.

78 Russell Manning and John Messner, “Case Studies in BIM Implementation for Programming of Healthcare Facilities,” ITcon 13 (July 2008): 446-457. 79 Filiz Ozel, “Building Information Modeling for Healthcare Facilities” (Microsoft PowerPoint, Arizona State University - College of Design, May 19, 2008). 80 Kathy Bell, “Mock-ups: Giving hospital clients the ultimate reality check,” Healthcare Design, May 1, 2007, http://www.healthcaredesignmagazine.com. 81 Phillip Dunston, Laura Arns, and James McGlothlin, “An Immersive Virtual Reality Mock-up for Design Review of Hospital Patient Rooms,” in (presented at the 7th International Conference on Construction Applications of Virtual Reality, West Lafayette, IN: Purdue University, 2007). 82 Kathy Bell, “Mock-ups: Giving hospital clients the ultimate reality check,” Healthcare Design, May 1, 2007, http://www.healthcaredesignmagazine.com.

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3.5. SUMMARY

BIM bridges between credible solid data information and the growth of EBD.

Currently EBD is based on some collected amount of reliable case studies. Items that

have been accepted as EBD are supported by these case studies or which some case

studies are repeatedly used as the backing for EBD arguments. Healthcare facilities

can be broken down into an understanding of healthcare modules – made up of related

spatial and component needs. BIM can be implemented under the umbrella of these

modules encouraging growth of reliable data supporting investigations of EBD. In all

aspects of the healthcare environment, the BIM process has the capabilities of

handling the various objects and specialized equipment which the healthcare

profession is greatly dependent on. In all these areas BIM is attuned to the

advancement of healthcare design.

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4. BIM STRATEGIES

Three BIM strategies for healthcare design suggested in this paper include

phasing, prototyping and application of baseline model. These are used for the

analysis in the investigation of this D. Arch project.

First, most healthcare project are planned on a general ideal timeline, as the

design team gains understanding about what the healthcare facility needs or what are

unique issues, the assignments and the timeline are adjusted.83 The importance of

managing timeliness in healthcare design leads us to investigate the BIM phasing

strategy. Evaluating and determining a set timeline and sequence of design events

creates moments for regrouping and previewing. Thereby, having more

accountability of completed work by phase rather than losing quality due to

negligence, miscommunication or incomplete tasks while proceeding on in a project.84

Secondly, layout of spatial relationships using prototypes allows the entire design

team to begin coordinating. Using BIM prototypes brings in information for all

participants on the project to begin observing what their responsibilities will entail on

the project. The BIM prototypes forecast for the various members of the design team

a large portion of their active role early on in the design process. Modifications and

adjustments are made to the design while commencing the sequencing of phasing.

Third, a strategy available by the completion of the project is baseline model – the

BIM model serves as a foundation for future reference or a base for redesign,

research, or other inquiries.85

83 Glenn Ballard, “Improving Work Flow Reliability,” in IGLC-7 (presented at the Seventh Annual Conference of the International Group for Lean Construction, Berkeley, CA: University of California at Berkeley, 1999), 275-286, http://www.leanconstruction.org/pdf/Ballard.pdf. 84 Glenn Ballard, “Can pull techniques be used in design management?,” in (presented at the Conference on Concurrent Engineering in Construction, Helsinki, Finland: University of California at Berkeley, 1999), http://www.leanconstruction.org/pdf/PullinDesign.pdf. 85 Orlando Maione, ed., “Open Building: A New Paradigm in Hospital Architecture,” AIA Academy Journal (October 27, 2004), http://info.aia.org/journal_aah.cfm

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4.1. PHASING

Phasing process with BIM provides the ability to forecast the development of

on-going design project and its schedule. Each control system includes a “look-ahead

window,” which is part of a scheduled structure. Activities according to a master

schedule are advanced through the look-ahead window. It gives a preview of the next

phase before the phase commences. Figure 9 below diagrams the concept of phasing

coordinated with a schedule on a timeline.

Figure 9 Overview diagram of forecasting/proceeding through BIM phasing.

With the ability to look ahead, assignments are made according to the project

units’ capacity. Completing sound assignments maintains productivity through each

phase of the project. The confidence comes from testing and then making operational

by exploding the activities in accordance with the BIM model.86 Using BIM to

86 Glenn Ballard, “Improving Work Flow Reliability,” in IGLC-7 (presented at the Seventh Annual Conference of the International Group for Lean Construction, Berkeley, CA: University of California at Berkeley, 1999), 275-286, http://www.leanconstruction.org/pdf/Ballard.pdf.

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evaluate phasing assignments before they are implemented supports necessary safety

precautions. Previewing a phase helps prevent loose ends in design or scheduling

before work is in motion. Whereas, in a traditional design process, most project

teams attempt to adhere to the long-term master schedule very closely. Decision-

making and maintaining consistent drawings throughout the duration of the project

can become tedious and can take up a lot of time and effort. The traditional design

process has less accountability on the project activities and causes less accuracy to

drawings and production. Specifically, coordinating phases is challenging on

healthcare projects due to complexity and liabilities that regularly drive the healthcare

market. Challenges arise especially during construction and even more so on

renovation projects. During healthcare renovation projects it is difficult building out

interior spaces of an occupied medical facility, safety is a high priority and managing

ingress/egress routes, infection control, required operational downtime and managing

temporary spaces are example of some of the challenges.87 For instance, a Magnetic

Resonance Imaging (MRI) machine weighs approximately 30,000 pounds.

Transporting this massive, expensive piece of healthcare equipment takes pre-

planning. BIM can be used to find a precise date in the construction schedule and the

optimal ingress route can be determined to ensure successful installation.88 Phasing in

BIM provides an integral and prompt coordination between systems within the design

documentation. It greatly reduces the contingency of delivering design intent with

unaddressed coordination issues between building systems. In the healthcare design

industry most of the problems occur in MEP construction coordination. Its cost goes

into, reaching numbers at about 45% - 55% of the total costs of the entire project.89

Delineating design tasks in phases are enhanced remarkably when scheduled is

supported by prototype modules reviewed throughout the later phases.

87 C.C. Sullivan, “Integrated BIM and Design Review for Safer, Better Buildings,” Architectural Record, 2007, http://continuingeducation.construction.com/article.php?L=19&C=213. 88 Graham Condit, “Complex projects call for virtual construction,” Seattle Daily Journal & DJC.COM, no. Health Care Design & Construction - Special Section (November 16, 2006), http://www.djc.com/news/co/11184025.html. 89 C.C. Sullivan, “Integrated BIM and Design Review for Safer, Better Buildings,” Architectural Record, 2007, http://continuingeducation.construction.com/article.php?L=19&C=213.

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4.2. PROTOTYPING

Defining a prototype starts from understanding a category. A category is

made up of families and within families there are types. Each time a type may exist in

a family, singularly or multiple times, each is known as an instance.90 This

relationship exists on different scales but regardless of scale, the relationship is

consistent. In the case of healthcare design, the category is healthcare and the

families are specialized spaces such as the exam room, patient room, etc. Types of

exam rooms are general purpose examination room, special purpose examination

room, observation room, and treatment room; from these prototypes are generated.

As prototypes are formulated, they are assigned to projects and the option to refine

prototypes is available. Prototyping in BIM maintains certain levels of organized

information preventing confusion or inconsistencies during the design process. It

makes information accessible after the completion. The primary computer application

utilized for this case study is Autodesk Revit 2010. In its data base, Autodesk Revit

stores the reference to Design and Construction of Health Care Facilities by the

Facility Guidelines Institute (FGI) and the American Institute of Architects (AIA).

The reference supports foundational parameters for the development of healthcare

design. It provides closely review the development of selected spaces in this project.

Furthermore, parameters according to these guidelines are implemented

through simulation function in the evolving process of prototype. In this process,

most basic attributes are accounted for and included into an initial prototype. Further

detail to the initial prototype relative to any project becomes a new level of prototype.

As illustrated in Figure 10. A later stage of an evolving prototype results in a physical

product. Variances and errors are likely to occur during and after the physical

construction of the building. The reality of a building is reviewed and taken into

account to consider for further development of BIM prototypes.

90 Revit. Architecture 2010 Imperial Tutorials. 2009. Autodesk, San Rafael, CA, Autodesk, Inc.

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Figure 10 Diagram depicting iterations of BIM prototyping.

4.3. BASELINE MODEL

A baseline model is a post-construction BIM model that was originally

developed during the design of the building as a new construction project or initially

integrated into a project of a building as a renovation/redesign project. This model

contains the previous design work and provides accurate information regarding the

building’s functions and attributes. Figure 11 illustrates a visual comparison between

a redesign project using tradition methods and the one with a BIM baseline model.

By the end of a project in a traditional design process, several connections of

information are lost or kept within the boundaries of specialized groups who worked

on the project due to the absence of a baseline model. However, a baseline model in

BIM becomes the basis of the well coordinated building information model through

various design phases. Passing on a baseline model for future design work or

renovations prevents uncertainty regarding the current state of the building. At the

completion of the design project the BIM model serves as a resource for future

inquiry. Referring to the BIM model as the baseline model for any future alterations

occurring later has made-ready information to be extracted from the model and a

record of ongoing work. The BIM baseline model becomes the key to the whole BIM

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process with consolidating large amounts of 3D data from different applications into

one model.91

Figure 11 Comparison between digital representation and BIM baseline model.

4.4. SUMMARY

While there are other directions which can be explored the chosen strategies

for implementation of the BIM process of design in this project is by using phasing,

prototyping and baseline model.

91 C.C. Sullivan, “Integrated BIM and Design Review for Safer, Better Buildings,” Architectural Record, 2007, http://continuingeducation.construction.com/article.php?L=19&C=213.

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5. CASE STUDY

In this section, the direction and goals are conveyed by communicating the

functional, spatial and other programmatic requirements particularly to a design

project using a traditional design process. Communicating these programmatic

elements is significant as it is adapted to the case study using a BIM process of

design. Comparisons between using the traditional process and a BIM process to the

pursue design goals are made based on the outcomes through a case study (Figure 12).

Figure 12 Images of the case study for the renovation of a primary healthcare facility.

5.1 PROGRAM

The case study is to renovate a primary healthcare clinic, one story building

concrete and steel framed structure. Originally constructed in the 1960s with minor

additions and remodels within the last twenty years, this building has approximately

8900gsf of existing structure, housing facilities which provide basic examinations,

imaging, pharmacy, laboratory, and minor surgical needs. The beginning phase is

considered new construction adding to a total of 14,650gsf by the end of the design

project.

In order to achieve different goals for the redesign of this building various

engineering disciplines encompass civil, landscape, structural, mechanical, plumbing

and electrical. Project goals are to 1) design an attractive facility that provides for

quality patient care and an environment that promotes healing. 2) Provide functional

space relationships that will optimize available space and provide for operational

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efficiencies and convenience for patients. 3) Also design facilities adequately for

healthcare services that meet current and anticipated needs. 4) Maintain compliance

with the current Life Safety and Code requirements and 5) design for flexibility in

adapting to future and changing needs of the health care delivery system and work

environment that promotes staff satisfaction.

While this building is undergoing renovation the design is managed in

construction phases throughout the existing structure using AutoCAD 2D

applications. The comparison comes from using a customized BIM process to perform

the same tasks involved in the renovation project. Reflecting on the comparison

between the traditional process and using BIM reveals the effectiveness of how

information is managed. BIM is employed as a liaison in the design process for

developing optimized BIM strategies in healthcare design.

Meetings were held to review and establish the functional and space program

for the clinic. Managers and client user groups met to establish functional space

needs, functional relationships and preferred adjacencies. Safety and security issues

were identified and addressed in the development of the design.

Space programming and the conceptual floor plan were developed by

referencing the comments made in meetings with the User Group. The User Group is

made up of key personnel including the Clinic Chief, Internal Medicine Chief, Clinic

Supervisor, Clinic Registered Nurse (RN) and Clinic Pediatrician. The department’s

preferred functional flows and current space deficiencies were analyzed based on:

room type and sizes, preferred room adjacencies, space deficiencies, what works and

does not work, current and projected needs and consolidation of shared work areas.

There are two parts to this project, allowing for some temporary transitional

spaces for staff and continuity of operation during the renovation of the clinic spaces.

Part one consists of Phase 1:

This includes a new Staff Lounge and lanai looking onto a cascading water

feature and landscaping and a new walking path with integrated fitness stations.

The basis of design for the Staff Lounge is a one-story structure, light gauge

steel framing and wood trusses, concrete slab on grade, exterior plaster and standing

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metal seam roofing. It entails sliding glass doors comprised of three walls that opens

up into an outdoor patio with views a tropically landscaped garden and cascading

water feature. The exterior elevation of the structure is intended to feel open airy and

with glass sliding doors that create transparency. Finishes are resilient flooring, paint

and an exposed ceiling.

Part two consists of the remaining Phases 2-4:

This includes renovation of the existing clinic spaces and new finishes

throughout the entire clinic. Within the renovation there is sequencing of work while

the clinic continues to be operational.

The basis of design for part two revolves around the renovation of the clinic

(pertaining to internal medicine, & Obstetrics/Pediatrics). This entails, remodeling

and expanding the pharmacy and adding walk up windows, providing outdoor seating

at the main entrance, the specialty clinic with separate entrance, remodeling reception

and add registration kiosks. Part two also entails renovation for team rooms, exam

rooms, shared injection/allergy room, behavior health room, social worker room,

triage, work-up stations and offices; plus, completely replacing both the existing

ceiling system and the existing finish flooring and then also adding guardrails at the

curb along the existing entrance.

Architectural design references for these two phases are:

AIA Guidelines for Design and Construction of Hospitals and Healthcare

Facilities – 2006 Edition

NFPA Life Safety Code 101 – 2003 Edition

Americans with Disabilities Act Accessibility Guidelines for Buildings and

Facilities

2003 International Building Code with local amendments

Chapter 93, Broad Service Hospitals of the Administrative Rules

City and County Zoning Codes

While there are other engineering disciplines involved in the design project.

The case study is pursued from an architectural perspective. Specific elements for

comparison are based on this perspective. These goals reflect the original project

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team’s plans using traditional methods of design. Selective goals are adopted into this

case study for comparison between using a traditional process of design and a BIM

process of design.

5.2 SUMMARY

The basis behind this case study is that is a healthcare facility undergoing one

phase identified as new construction and a number of following phases identified as

renovations. All the phases of construction occur with the services of the healthcare

facility remaining active. While the actual project is performed using a traditional

design process and 2D applications (Figure 13 – 17) the case study is performed using

a BIM process as a means for contrasting the result and findings between the two,

specifically from the architectural standpoint.

Figure 13 2D CAD existing design.

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Figure 14 2D site plan.

Figure 15 Scanned 2D topographic site plan.

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Figure 16 Developing design using a traditional approach.

Figure 17 Changes during design process.

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6. DESIGN MODELS

In this project the utilization of BIM in healthcare design is explored through a

few strategies: phasing, prototyping, and application of baseline modeling. These

strategies are applied to a case study with is set up as an adopted scenario to an actual

project which is processing through design with a more traditional approach. The

processes of using these strategies are exemplified in this section. For each strategy a

number of examples can be shared but this project only a couple of examples

exploring the support of BIM to healthcare design are emphasized.

6.1 PHASING: TEMPORARY BARRIERS AND EGRESS ROUTES

Figure 18 The case study project adopted into a BIM process had one new construction phase and four remaining renovation phases.

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BIM involves integrating information to and from different sources, tools and

applications. Phasing the project (Figure 18) produced in Revit initially will be

outreached to other management information tools. This is an example of BIM

processing in phasing. The sharing of information between modeling a design and

managing the phases of the project are observed in this process. Figures 19 – 28

reveal phases of the project in order.

Within Revit alone, the project has been phased and all drawings and

components are simultaneously coordinated based on the treatment of each phase.

The order of demolition and new construction mimic reality. For example if a wall

was demolished in a previous phase, it will not be available for alteration in later

phases within the design project. Plainly, this reflects reality.

By initially phasing the design project, the information pertaining to each

phase is maintained throughout different levels of coordination. Extracting

information is manageable by phasing out the design. Upon coordinating activities,

objects, equipment and spatial requirements the necessary information is contained

during each phase. Also, scenario testing for each phase is also possible with

extracting individual phases for analysis. Having the ability to maintain the entirety

of the project but also work in isolated areas according to a scheduled timeframe

allows for monitoring a range of items and activities which go on during the design

and construction process.

In the case study for the renovation of a healthcare facility monitoring the

construction phases are very important since the services of the existing structure are

to remain active. Having the ability to anticipate necessary means for safety can be

more accurately accounted for by phasing out the design in this BIM process. Two

critical aspects of safety in an active healthcare facility during construction is 1)

monitoring temporary barriers which contain the atmosphere during construction from

leaking into active healthcare spaces which can be detrimental to the wellness of

patients and healthcare professionals and 2) managing the appropriate temporary

egress routes during the renovation.

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Figure 19 Existing phase.

Figure 20 Phase 1 – new construction.

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Figure 21 Phase 2 – demolition.

Figure 22 Phase 2 – temporary barriers.

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Figure 23 Phase 2 – continued demolition.

Figure 24 Phase 2 – new construction.

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Figure 25 Phase 3 – demolition.

Figure 26 Phase 3 – new construction.

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Figure 27 Phase 4 – demolition.

Figure 28 Phase 4 – new construction.

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6.1.1. Monitoring temporary barriers

As the design of the healthcare facility develops in Revit, phases are created to

communicate existing, temporary barriers, demolition and new construction.

Organizing the priorities during the construction process through phases establishes

increased accountability during the actual design process. Using a BIM process of

design allows building professions to schedule in advance the desired outcomes

within a time frame. Figure 29 diagrams the phasing and scheduling relationship.

Previewing the phases enables the healthcare professionals to gain awareness early on

of the procedure that will be occurring throughout the duration of the construction

process. This is important in this case study because the clinic will still be actively

providing their healthcare services during the construction process. Additionally

when phasing the planned and actual outcomes, the correlating phases can be cross-

referenced. The capacity set for the next phase can be based on the actual outcome of

previous.

Revit as a BIM tool can outreach and communicate with other helpful BIM

tools. Phasing is based on how the information is prioritized and arranged to

communicate with each other. For this example, monitoring barriers such as the

demolition, temporary and new construction is highlighted and also preventative

action barriers based as an organizing priority in the design of this healthcare facility.

Barriers are preventative actions against unwanted circumstances accessing

uncontaminated areas. Every phase carries a separate view focusing on each of those

categories. Other BIM management tools such as Navisworks cooperates with BIM

scheduling tools such as MS Project, Primavera, ASTA Power Project, etc. and other

BIM tools involve environmental analysis, all of which have the ability to

communicate and transfer information from the Revit project. This sharing of

information allows the ability to schedule the project on a time line and check the

planned portions against the actual production.

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Figure 29 Phasing scheduled tasks communicate status and capacity of production by comparison of planned and actual outcomes.

The Revit project is a repository of information regarding the design which

allows for scenario testing, data inquiries and real time visualizations of the design

process. By scheduling the appropriate temporary barriers it decreases the

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vulnerability of active spaces during renovation. Also in partnership with temporary

barriers, the use of high efficiency particulate air (HEPA) filters has been identified as

necessary for use on healthcare renovation projects. Along with temporary barriers,

these pieces of equipment which prevent the air quality from digressing can be

scheduled in the needed locations. A healthcare facility is considered a protective

environment. Guidelines under the Center for Disease Control (CDC) recommend

design that includes infiltration and ventilation control, directional airflow and

pressure control.92 With reference to the specific phase of the design, space can

undergo analyzing with Computational Fluid Dynamics (CFD) modeling and thereby

supports decisions concerning if the number of HEPA filters being used is adequate

and if they are set in appropriate locations.93 Figure 30 diagrams the possibility of

the case study project pharmacy space with its associated massing in association with

the image of a previous lab pharmacy which underwent CFD modeling analysis. The

opportunity to include CFD modeling is definite in the BIM process of design. Data

from an additional analysis such as this also opens large contributions of information

to further EBD. These are examples of phasing in different types of information or

analysis options. Overall, phases are based on priorities to building design and

construction assignments set on a timeline. Decisions on how these items are

prioritized in the phasing of the design project will enable useful information for the

design and construction of a healthcare facility.

92 “Meeting Healthcare Guidelines with CFD Analysis,” Where Design Meets Excellence, 2006, http://www.dfwcgi.com/services/Studies/CFDforHealthcare.htm. 93 Bob Hansen, “New health care design guidelines emphasize infection control measures,” Austin Business Journal, no. February (2005), http://austin.bizjournals.com/austin/stories/2005/02/14/focus5.html.

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Figure 30 Phasing Pharmacy space relationship to example Laboratory CFD modeling analysis.

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6.1.2. Managing temporary egress routes during renovation

Communicating egress can be done in different ways, during phases in

construction and egress path is created as a family (Figure 31) and can be assigned to

the different phases (Figure 32); it is a component so the egress path can be treated as

existing, demolition and/or new construction. Assigning proper egress for each phase

remains coordinated on the timeline that each phase is developed for. In the same

way, phasing out the egress paths can be coordinated with scheduling and checking

for proper treatment for temporary egress paths during construction can be reviewed

in advance and checked against the plan for egress with the actual outcome of the

construction process. Aside from coordinating drawings and scheduling, visual aids

for understanding egress can be reviewed with animations generated from the BIM

model. The safety of users within active areas of the healthcare facility is high

priority.

Figure 31 BIM coordination of egress routes along with schedules.94

94 Steve Stafford, “Revit OpEd,” Blogger, Room Name - Full or Abbreviation, December 15, 2008, http://revitoped.blogspot.com/2008/12/room-name-full-or-abbreviation.html.

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Figure 32 Establishing temporary egress routes during renovation. Coordinated and visualizing the egress routes according to phases.

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6.2 PROTOTYPING: RULES AND INTEGRATION

This investigation involved setting up rules and spatial needs to create a

prototype for a specific healthcare space. A diagram shown in Figure 33 shows the

relationship between the rules, prototype and output data. Achieving prototypes

which meet foundational requirements for healthcare design is based on various

guidelines established for the design and construction of healthcare facilities. Upon

creating a prototype, the following action is integrating the prototype into a project.

In doing so, some manipulation to prototypes may be necessary depending on the

specific project. Some spaces within a healthcare facility are repeated in layout

whereas some only exist in a facility as a single standalone space. Some examples of

repeated spaces may be exam rooms, patient rooms, and/or nursing stations and so

forth. Contrary to this as an example would be a pharmacy which is only necessary as

a single entity in a healthcare facility. Two example prototypes (Figures 34 and 35)

are explored and used to communicate the setup of a healthcare prototype and the

integration of a healthcare prototype into a project. Setting up a healthcare prototype

is explained through the example of the General Examination Room Prototype.

Integration of prototypes into a project is exemplified using a pharmacy prototype.

Exploring the setup for an exam room prototype and integration of a pharmacy

prototype into a project contributes various findings.

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Figure 33 BIM Strategy: Prototyping.

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Figure 34 General Examination Room Prototype.

Figure 35 Pharmacy Prototype.

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6.2.1. Rules – setup BIM prototype parameters

Prototyping begins with reference to Guidelines for Design and Construction

of Health Care Facilities, the National BIM Standards, and a few other reliable

reference materials.

A general examination room is the most basic of health care spaces. To start a

new BIM prototype project this general examination room is chosen to explain the

process. The strategy for initially setting up a prototype for a particular healthcare

space is to begin with the necessary space and the primary use of the room including

the most important component that will be used. These prototypes will be referencing

the 2006 Guidelines for Design and Construction of Health Care Facilities. These

guidelines include the following (Figure 36):

Figure 36 list from Guidelines for Design and Construction of Health Care Facilities 2006.

Based on the recommendation of these guidelines a few actions were decided

upon for starting a new BIM prototype project which include 1) setting parameters for

a Desired Area, 2) obtaining appropriate components, 3) setting parameters for

clearances and 4) setting schedule parameters. The actions for prototyping in relation

to the guidelines are highlighted in Figure 37.

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Figure 37 Parameters selected for prototypes based on the relationship to the healthcare guidelines.

The exam room has guidelines concerning the floor area. An exam room

prototype is a typical example or basis for further design and development in a

healthcare design project. Using a conceptual model will help to explain the process

for creating constraints for the prototype. In order to setup a prototype understanding

the relationship of parameters to their respective objects, components and/or families

is necessary. Using Reference planes, Dimension parameters and Formulas a Desired

Area can be defined within Revit.

The first action is setting parameters for a Desired Area. For this portion in

explaining the start of a prototype the first action is to set parameters for a Desired

Area. This is initial action is chosen because different healthcare spaces have

guidelines regarding minimum floor area. Defining a Desired Area parameter

supports the necessary guidelines set for healthcare spaces. In order to conceptualize

the process of setting up parameters in Revit as a generic action the explanation will

be based on a mass object representing a room space. As illustrated in Figure 37. In

creating a mass family it allows for the process of laying out parameters based on

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reference object, line, and/or space. By creating reference lines on a level one

reference (XY coordinates plane), Revit can manage the calculated space. Naming

the Reference lines (Top, Bottom, Left, Right) is important for mapping out the

direction and behavior of the object which these parameters are being defined for.

Equalizing the distances of the references lines from the (0, 0) XY coordinates

supports the mass to be proportional. Drawing the lines so they make an orthogonal

rectangle allows visualization of a box shape. Then a rectangle is drawn within those

reference lines boundaries by selecting the reference plane datum option.

Dimensioning 2 orthogonal sides of the reference box opens the option to make a new

dimension type parameter and name the sides according – length and width. Then by

selecting the Family Types option, the parameters appear. By selecting “Add” under

the parameter section create a “Desired Area” dimension parameter. Since these

parameters are named and associated to spatial value, formulas can be created to make

mathematical relationship between the sides of the box. For example, (Figure 38)

“Width = Desired Area / Length.” Following these same steps for creating height in

an elevation view is another optional dimension option. When finished to see the

results of the automatic dimensional relationship developed based on setting

parameters can be view by creating a form from the reference box on the reference

plane. Locking the surface planes of the box to the reference plane set with

parameters will hold the object to the relationship of parameters that were created. In

the 3D view selecting the move option the automatic response of the length and width

of the box object reflect the relationship made be creating the parameters when

dragged in different directions.

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Figure 38 Arranging and setting parameters for Desired Area for the exam room prototype.

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The second action in starting a new prototype based on the guidelines shown

in Figure 36 is obtaining appropriate components for BIM prototyping. Realizing the

primary components of the healthcare space for which a prototype is being created is

preliminary. Referring to appropriate guidelines, primary components required in an

exam room is the exam table, a hand-washing station and documentation space.

Gathering these important components can be done using the given library within

Revit or from other resources. However, the only standard components made

available for easy access at the beginning of new project are most commonly wall,

door, window, components. For the exam room an exam bed/table is needed which is

not made available at first. Loading components from the Revit Application – Library

is one way to find the component need. These components are typically known as

“Families.” A fundamental aspect of the BIM process is the quality and quantity of

information included in a model, so in selecting component families it is critical to

select components which are informed based on reliable sources as well.

This exam room needs a different exam table rather than the one available

through the Revit Library. There are online resources where Families of components

can be downloaded, uploaded, for a price or for free – available through open source

forums. Some examples are: Autodesk Web Library, Autodesk Seek, Revit

Architecture Market (beta), Revit City, Revit Components, and ARCAT (under BIM

Objects), etc. Commonly used is the Sweet Catalog which now includes a BIM

collection. Illustrated in Figure 38 are two options of exam tables available through

an open source site, called Revit City. In setting up this prototype the component

Doctors_Large_Exam_Table_2781 (top option in Figure 39) is selected. Saving the

components to a file library in the computer is then also available for future use as

well.

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Figure 39 Components from Revit City can be downloaded for this exam room prototype.

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Beginning this prototype, basic components used are chosen according to the

guidelines. After identifying basic components we also are aware of the guidelines

which pertain to features within the exam room. Clearances are necessary around any

furniture in an exam room. For example, according to guidelines the minimum

clearance for the exam table is 2 feet 8 inches around it. Taking into account the

requirements for a hand-washing station and documentation space, selecting a sink

component and counter top component aim to fulfill these guidelines. Selected

components for developing this general examination room prototype are illustrated in

Figure 40. When a project is saved or a component is saved as a family, this is the

beginning of a file library. This will be the start of a “Healthcare Design Library.”

A third action for starting this prototype is setting parameters for clearance.

Guidelines require features within healthcare spaces to maintain particular clearances.

Every prototype space has a location with a folder containing the project files and

component files. While the components are saved to specific project locations

creating a General Healthcare Design Library for Components is appropriate for

future use.

Figure 41 shows by selecting the family component exam table for editing,

reference lines can be created around the form of the exam table in the reference plane

view. Draw reference lines parallel to each edge of the exam table. With these

reference lines dimensions can be placed between the exam table edge and its

correlating parallel reference line. Selecting all the drawn dimensions a new

dimension type parameter is created. By inputting the distance 2’-8” each reference

line with a dimension parameter associated to it will automatically adjust to that

distance, thus setting the requirements for any furniture necessary for the general

examination room prototype. By drawing hidden lines with the “select line” option

the clearance for the component can be visible in a project. Now when components

carry this parameter the clearance recommended can be visualized during the design

process. Also the option to turn off the visibility of the represented clearance can be

done through the properties of the exam table family component.

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Figure 40 Components utilized for starting an exam room prototype.

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Figure 41 Creating parameters to reflect necessary clearances for the exam room prototype.

As prototypes develop over time or components becoming altered due to

changes in guidelines and so forth, new iterations of the prototypes can be saved as

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edited file. A simple file management action is duplicating this component within the

current project and changing the file by adding “e1” to the end of the file name keeps

the original file and allows for the component to be altered according to a project’s

specific needs. Keeping the original name gives the ability to reference back to the

original download. Adding “e1” is similar to saying “edit 1” and with every new

change the end of the file name should be saved according to the number of

alterations. (e2, e3, e4….) This project will contain the project components under its

own file location (My Healthcare Design Library > Examination Room >

COMPONENTS > Doctors_Large_Exam_Table_2781e1)

In the same way an exam table is loaded into this project, families include

countertops, cabinetry and sinks which are also loaded into the project. This is one

example of apply information relative to healthcare design and putting it into a

modeling system. There are many other pieces of information which need to be

implemented into a modeling system. The basis of this research rests on the idea that

building information modeling can house the imperative information relative to

healthcare design.

For the start of this prototype another action is setting schedule parameters.

While some parameters are arranged to depict accurate visuals of spatial needs,

setting parameters within a schedule support monitoring specific data particular to

healthcare needs. As one example, the schedule conveys data information concerning

the room area (Figure 42). In a project a room is defined by room bounding objects

such as wells. By selecting the room tool and the space which is desired to be

defined, Revit can then recognize the room space. Within the room tool an option to

calculate Areas and Volumes is available. By creating a new room schedule options

for arranging the information can be done using fields, filters, sorting/grouping

options, formatting, and/or appearance. By selecting the option to create a Calculated

Value Naming it “Room Floor Area SF” a formula can be defined for calculating

“Room: Volume / Room: Unbounded Height” will generate the result of the Room

Floor Area.

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Figure 42 Unique parameters set in healthcare prototypes are supported by calculated data conveyed in schedules.

While the Desired Area parameter previously mentioned is created and can

visually reflect area requirements in the model, the data of actual calculated square

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feet is communicated directly into the schedule. Using formulas to establish

calculated values becomes added accountability on the prototype. Reviewing the data

in schedules is an accurate check on the design of the prototype model in reference to

the guidelines laid out for different healthcare spaces.

With the understanding of these actions 1) setting parameters for a Desired

Area, 2) obtaining appropriate components, 3) setting parameters for clearances and

4) setting schedule parameters the following two sections exemplify this setup for an

exam room prototype and a pharmacy prototype according to the recommended

guidelines.

6.2.1.1. Rules – General Examination Room Prototype

Prototyping for healthcare spaces using the basic parameter setup for Desired

Area, Clearances and Scheduling is demonstrated in the development of a General

Examination Room Prototype. With the parameters and family components set up

they are simply loaded into the project. Loading in the necessary components can be

done in any order. However, a suggested order for prototyping healthcare spaces

illustrated in Figure 43 is the Desired Area which communicates minimum area

recommended by the guidelines, then the components with clearances along with

drawing walls. After placing all these parts that make up an exam room, schedules

can be included for managing the spatial information such as the Room Area SF

mentioned earlier and/or other items involved in the project defined by the schedule

properties. This is just one example of applying the customized rules setup for an

exam room prototype.

In addition to this, other derivatives of a general examination room can be

developed by making alterations to an original prototype and saving the project file in

the name of the new space. Figure 44 shows the original general examination room

prototype reconfigured to develop an observation room prototype. This prototype of

an exam room is executed with reference to guidelines for the design and construction

of healthcare facilities. Using the General Examination Room prototype variations

can be made and saved as new files thus providing base prototypes for different types

of exam rooms. Guidelines convey exams rooms aside from the General Examination

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room, which are Special Purpose Examination Room, Treatment Room and

Observation Room. From the initial General Examination Room prototype, new

prototypes can be developed based on guidelines for these other types of exam rooms

without returning to tabula rasa. These other types still maintain strong similarities to

each other. Therefore prototypes build and expand from each other. This is the

beginning of creating and investigating BIM prototypes for healthcare design.

Figure 43 Parameters inspired by healthcare guidelines used for a General Examination Room Prototype.

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Figure 44 Observation Room prototype is developed from General Examination Room Prototype.

6.2.1.2. Rules - Pharmacy Prototype

In the case of setting up guidelines for a pharmacy a template (Figure 45) was

available in a 2D AutoCAD format. Using the AutoCAD file as a reference and

underlay provided some level of collected information. Rather than setting

parameters inspired by design guidelines for healthcare facilities, such as in the

example of the General Examination Room prototype, this prototype begins its setup

based on credible digital template information provided by the client. The value of

using the 2D template is mostly that it communicates given dimensions. The

prototype developed using a BIM approach has a basis from the template.

Researching information from the 2D template is made reference similarly to

researching information in the guidelines for healthcare facility. The one larger

difference is having dimensional compatibility between digital files, but the data in

the 2D template is not coordinated automatically into BIM tools, such as Revit.

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Figure 45 Pharmacy prototype is based initially on the dimensions of the 2D template.

Referring to the CAD template, some rules and components are identified.

This is a manual transfer of information (Figure 46); similar to referencing

information in a book, except in this case it is in a different computer application tool.

Once components are identified they can be gathered, using the same approach as

mentioned in developing the exam room prototype, to produce a pharmacy prototype.

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Figure 46 Typically manual referencing of information between 2D template into Revit.

While several components are available to include in the prototype, a

pharmacy requires some very specific pieces of equipment. Some components have

been produces and contributed toward open source sites such as a ducted laminar flow

fume cupboard (Figure 47), used in some pharmacies. This is just one example.

Figure 47 Pharmacy equipment – Ducted laminar flow fume cupboard component.

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Using the available components and the 2D CAD template for limited

dimensioning reference a pharmacy prototype is developed. While the need for

pharmacy spaces is not repetitive in the layout of a healthcare facility the prototype

serves as a basis for different design projects. The pharmacy prototype (Figure 48)

contains the fundamental needs for a functioning pharmacy design and

reconfigurations can be made depending the unique needs and details of individual

design projects.

Figure 48 Pharmacy prototype.

Acquiring components for specialized professions still depends on open

source availability. Sometimes components are provided by a manufacturer, the

Sweets Catalog has been a common source for obtaining particular product needs.

Lately the Sweets BIM collection has been growing. However, registration and other

account type requirements are necessary for access to their growing library of

products. If components for pharmaceutical equipment or other healthcare spaces are

unavailable basic components can be self-produced representing approximated

detailing for the sake of the project or can be represented by dimensioned forms

mimicking the required component. Importantly, BIM is about having informed

modeling so the quality of information is critical to the worth of the BIM model

outcomes. BIM modeling is dependent on the available information. In time as more

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information is received, BIM prototypes are flexible to exchange or received new

information.

6.2.2. Integration – utilizing BIM prototypes into design projects

A prototype carries foundational information and is setup according to the

appropriate rules and guidelines for the specific healthcare space. Because of the

coordinated information that the prototype withholds the key to integrating the

prototype into a healthcare design project (Figure 49) is have all the information

transfer without losing any information or losing the proper coordination of

information. For the case study, a portion of the project is renovation of an existing

structure. After demolition of some existing structure, is redesigned requiring a

couple of general examination rooms in a specific location. During the BIM process

of design, integrating the general examination room prototype accomplishes design

needs and maintains the original prototype information. Rather than design

traditionally and controlling each component piece by piece and then checking each

detail to make certain that all aspects are abiding by healthcare guidelines. The

prototype already includes all the calculations.

Figure 49 Integrating General Examination room prototype and Pharmacy prototype into a design project.

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6.2.2.1. Integration – General Examination Room Prototype

Within Revit the option to link one Revit project into another is available but

for simply beginning the process of integrating a basic prototype. The common

method of copying and pasting works as well. For this exam room prototype,

regardless of what option chosen to integrate, once it is brought into the healthcare

design project, creating it as a group and naming by its prototype name within the

project will support managing the overall project throughout the duration of the BIM

process. As long as the prototype exists as a group, the components within will be

maintained. Some alerts occur (Figure 50) when placing the prototype within the

renovation project. Walls representing decided space allocation for the examination

rooms exist in the design project. When integrating the prototype, an alert is

recognized. There are conflicts in the walls, in order to maintain the integrity of the

prototype, opening up the group, cutting the walls so the prototype wall is the host

maintains certain components with a wall dependent relationship. In this case, wall

dependent components for the exam room are the upper cabinets and electrical

outlets. Making this adjustment in the group itself, maintains the prototype and

allows for it to be placed amicably into the renovation design project.

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Figure 50 Integrating and using prototypes in a design project.

In this case, the decision was to have two exam rooms next to each other.

While this is a renovation project, some walls must be maintained. Creating a second

instance of the general examination room group that was initially created up on

integrating the prototype is used for executing the second examination room space. In

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the case of other projects, perhaps a new construction project, an advantage behind

this is maintaining prototypes as groups allows the ability to make changes and

maintain coordination to all rooms placed in a design. Because of space constraints in

the renovation project an exact replica of the exam room cannot be used. So when

placing the instance and creating it as a new group will allow for unique adjustments

without having influence on the earlier integrated prototypes. The groups define the

relationship of any new configurations to the prototypes.

These are the basic actions involved with integrating a prototype for a general

examination room into the case study of a renovation for a primary healthcare project.

6.2.2.2. Integration – Pharmacy prototype

The same way the exam room prototype was integrated into the project, so is

the pharmacy prototype (Figure 51). Prior to including the pharmacy prototype was

designed a space for a waiting area. Since the pharmacy prototype contains a given

waiting area, it is not needed for the project. When the pharmacy prototype is brought

into the project and made into a group within the project. Then actions toward

reconfiguring the space can occur. Removing the waiting area from the prototype, the

pharmacy is now configured to the needs and space constraints of the existing

structure as shown in Figure 52.

Figure 51 Integrating a Pharmacy prototype into a design project.

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Figure 52 Integrated Pharmacy prototype.

6.3 BASELINE MODEL: CONTINUITY THROUGH BIM

The purpose resting at the root of BIM is the consistently consolidated

exchange of information which makes available the ability to make simultaneous and

coordinated actions to a design project. Utilizing the BIM process is not contained in

one design project but can be implemented throughout the duration of a building’s

lifecycle. Buildings undergo change with time and BIM supports these changes.

Applying baseline modeling provides the foundation information to lead into future

changes more effectively. In the case of healthcare facilities, aside from common

changes to a building, the expansion of the healthcare profession requires changes and

improvement in the buildings facilities as well. Observing a couple of approaches in

the BIM process of design, post-construction actions by applying baseline modeling

makes available information regarding the healthcare facility environment for

research and the advancement of healthcare design as a whole. Two examples of

applying baseline modeling are 1) sharing of the BIM model designed in Revit

through other cooperative applications and 2) using information databases having a

coordinated relationship to the model.

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6.3.1. Continuity and sharing of BIM model

After a healthcare design project is entirely complete and made fully active, it

is expected that in the future post-construction inquiries are made with relation to the

healing environment or anticipated design alterations. Applying a baseline model

provides detailed information of latest building design attributes. The baseline model

offers data about the environment which healthcare professionals can investigate with

respect to the healing environment. The baseline model also offers a solid foundation

of information which can be utilized for future building designs or renovations.

Applying baseline models for the sharing of prototypes with healthcare professionals

contribute data which can be used to investigate the healing environment for specific

areas of a healthcare facility. Figure 53 illustrates that designers can pass on a

baseline model to the client and control the level of information they are willing to

make available without the client needing to use a complicated architectural design

application. The baseline model is exported as a specific file type or saved through an

add on in the Revit program. This allows for the BIM tools to communicate the BIM

model to one another. Among other BIM tools the model can offer can undergo other

levels of analysis, or observation depending on the purpose of inquiry.

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Figure 53 Example of applying baseline modeling by exporting BIM model into other BIM application tools.

Using Revit for the case study, a compatible application for producing some

levels of a baseline model is using Autodesk Design Review. Within Revit, an option

for exporting different file types is what allows for a controlled sharing of

information. By exporting the design project to a DWFx file it produces the model in

a format which does not allow for direct design alterations, but does allow the ability

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to inquire into the details of the design project. This format is analogous to printing to

a PDF file. There option to alter the design is not available but the details for

reviewing, marking up, commenting, measuring is offered for the sake of inquiry.

This file format is more strictly a visual exploration of a baseline model.

On a smaller scale, baseline models of BIM prototypes contribute specific

information about the unique spaces in a healthcare facility. For example Figure 54

shows the start of a BIM prototype for a patient room which is one area that is

researched for EBD application. For future studies a baseline model of this space can

be shared with researchers so they can apply the data as contributing results toward a

specific research topic. Apply the use of a baseline model exported from BIM

prototypes supports healthcare designers and healthcare professionals the solid data

for investigating the healing environment. Without formal publication, the

information cannot be considered official case studies, however applying baseline

modeling does supply solid data on which investigations for formal case studies can

build upon.

Figure 54 Baseline model of a BIM prototype for a typical patient room.

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6.3.2. Continuity and sharing of BIM data information

Another example of baseline modeling is using the BIM model and

establishing a direct and continuous transfer of information to a database system. In

this example situation (Figure 55), changes in the model and/or changes in the

database system has simultaneous interchange and affect on each other.

Figure 55 Baseline model of a BIM prototype for a typical patient room.

Networking a database system involves setting up a network through

administrative tools in the operating system of a computer. Using Data Sources for

Open Database Connectivity (ODBC) a data source is created for transferring the

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Revit project data into a collection using spreadsheet tables. From the other end of

the connection within the Revit application a plug-in for external tools is to be

downloaded. The plug-in is Revit RDB link. With this link communication is

established between the project model and the spreadsheet for managing data

information.

The relationship between the BIM model and the database system

makes it feasible to make alterations to features in the model and then the change

automatically is coordinated in the database. This also works in reverse; if you

change items in the database system it will make changes to the model.

This example allows accessibility to the details of the project. The

availability of information this baseline model offers enables future design decisions

to be based on the awareness of previous design information. It also enables

healthcare professionals to be more aware about detailed information regarding the

healthcare environment.

6.4 SUMMARY

In this section, three strategies, phasing, prototyping and application of

baseline model, are pursued for the BIM process implemented into a case study

project for a healthcare facility. Along the lines of phasing, the ability to setup the

phases according to priorities in healthcare design allows building professionals and

healthcare professionals to look ahead at the actions and activities necessary to

monitor during the design and construction process. Phasing allows for increased

awareness of safety and supports preventative managerial actions for monitoring the

priority issues of a protective environment of the healthcare facility. Prototyping

establishes a consistent and ongoing means of scenario testing. Using prototypes for

scenario testing requires setting up appropriate rules and parameters in order to make

specific evaluations base on detailed alterations. Prototypes are also a basis for

specialized healthcare spaces which can be integrated into healthcare design projects

and can be further developed as an isolated part of the whole design. Applying the

use of a baseline model provides a sound foundation of information to be shared for

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future design projects or redesign of the latest existing structure. The data which

baseline models carry is very useful for future developments in healthcare design for

both healthcare designers and as a contributor to the advancement of the healthcare

profession.

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7. OUTCOMES

BIM model communicates between various BIM tools, for this research the

primary and initial BIM tool used is Revit. Communication of data is coordinated and

is shown in a few images of compatible BIM tools in the processing of understanding

the relationship of information between various methods of analysis.

In Figure 56 the use of Revit to initialize a BIM model reveals various views

in scheduling, 3D section views, plans and walkthroughs. The infrastructure of the

BIM modeling process for design begins with the information input into Revit. The

detailed pieces of information, from GIS generated topography to voltage information

for lighting systems (Figure 57) are put into the Revit model and communicate out to

various other BIM tools. Transferring detailed information from Revit also includes

the groups made from integrated prototypes and the customized scheduling

information (Figure 58). This is the chosen BIM tool for this research to begin with

establishing the design. In Revit all views can be organized with the phasing strategy

and transfer into other BIM tool applications.

Figure 56 BIM modeling in Revit.

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Figure 57 BIM modeling in Revit of lighting details and GIS imported topographic form.

Figure 58 BIM modeling in Revit of prototype grouped and scheduling on a sheet.

Using the original BIM model devised in Revit, the transfer of data and model is

shared in the application Navisworks. Navisworks is not an application for creating a BIM

model rather in this BIM tool application is where a relationship between all the information

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set up in Revit is networked with a schedule created in another outside information

management system called MS Project. However Navisworks is the information management

system which can coordinate the scheduling with the BIM model (Figure 59). The different

details involved in scheduling can be viewed using this tool as well (Figure 60). This affirms

the correct items are connected with the appropriate scheduling information.

Figure 59 BIM model coordinated from Revit to Navisworks information management system

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Figure 60 Detailed items of BIM identified with detailed coordinated scheduling.

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Another BIM tool application which information from the original BIM model

transfers into is Design Review. A casual way of describing the viewing features of this BIM

tool application is like viewing a .pdf file. The BIM model brought into Design Review

allows users to make minimal automatic coordination with other outside tools. This simply

holds information for viewing and making notes without tampering the actual BIM model.

Figure 61 is an example of a view with options to navigate around the model. Part of using

Design Review is also for the ability to select different objects to make inquiries about the

details (Figure 62). Information included in the original BIM model can be shared for review

and notes can be directly added in with association to the reviewed items. While the markup

is created primarily for the building industry (Figure 63), it is still usable for others such as

healthcare professionals to use when reviewing a design for a healing environment.

Figure 61 BIM model coordinated from Revit to Autodesk Design Review information sharing system.

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Figure 62 BIM model in Design Review – detailed objects inquiry

Figure 63 BIM model within Design Review marked-up for review.

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MS Access is an information database system. By using the Revit RDB link a

continuous access of information can be communicating between the original Revit model

and MS Access information database through an ODBC connection. This sharing of

information contrasts Design Review. Design Review does not allow for a transfers to and

from each BIM tool application whereas with through ODBC MS Access and Revit can affect

each other. The visual objects seen in Revit are not visible in MS Access however the

information connected to the objects is in MS Access. Changes to the objects or changes to

the database information will alter each other directly. Different types of information are

organized in appropriate categories which are consistent with the organizational setup in

Revit as well. Figure 64 shows the database information related to the Revit model.

Figure 64 BIM model coordinated from Revit to MS Access database system.

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8. DISCUSSION

In this research, the needs for BIM in healthcare were identified by the

fundamental nature of the healthcare profession in the scope of the provided

diagnostic/treatment involved in their service, the functional space necessary to house

the services and the tools/equipment which healthcare professionals are dependent on

to provide the appropriate care. All of these parts in the nature of healthcare are

affected by the environment. Ultimately healthcare design is directed toward pursing

healing environments through by means of Evidence-based Design (EBD). From this

BIM is realized to be a link between healthcare design and the healthcare

professionals due to the purpose of coordinated data transfer which BIM offers and

the necessary reliable data required for EBD.

Investigating the connection between BIM and healthcare took researching the

environment of patients and caregivers through established EBD knowledge. The

investigation also entailed understanding that through BIM and assembly of organized

parts in healthcare are managed as healthcare modules providing accessibility for

building design configuration and inquiry in an isolated mode. Additionally,

tools/equipment is included in the exploration of BIM and healthcare due to the

necessity of the equipment for healthcare services.

Findings reveal that the initial setup for applying Building Information

Modeling (BIM) in the healthcare design took a significant amount of time. This

involved making decisions about what types of information are foundational and have

priority throughout the design process, which front-loads important decisions. The

decisions for what types of information and how the information is processed

determine the outcome of available data. A large sum of these decisions would be

involved in pre-design level of project, even more so pre-project. Healthcare

designers and professionals would need to establish the priority of healthcare design

issues prior to actual design work. In doing this, the detailed information desired to

evaluate for the advancement of healthcare design would also contribute to the growth

of EBD.

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While BIM is more commonly applied in the design and construction industry,

the methods for BIM in healthcare design are different because the information

contributes largely to the healthcare design and the healthcare profession. Both

building and healthcare professionals are responsible for continuous information

exchange in order to utilize the collected data with BIM for applying EBD in the

process of healthcare design development. Recognized in this research is that BIM

tools are more adequate in managing building industry issues and while they can be

useful to healthcare professionals, either one of two things should be considered, 1)

the commonly recognized BIM tools can be somewhat shoehorned for the purpose of

evaluating information and data according to EBD or 2) it is necessary to identify

compatible healthcare data management systems and include them in the collection of

BIM tools as contributing means for healthcare design.

The phasing, prototyping, and baseline model of BIM become a solid

foundation for updating future redesign projects and as a standalone report of

collected data for contributing to EBD. Each of these strategies are founded on the

decisions for setting up rules and parameters in order to produce outcomes which

reflect detail issues desired to be evaluated in healthcare design. The decisions for

specific evaluations are included in the early stages of the design process. The

reliability of data outputs is defined by the input setup of rules in BIM tools and how

they communicate with one another. This is dominant in phasing and prototyping.

The role of phasing is most in sync within the frame of design and construction;

outside of that arena its usefulness is yet to be clearly determined. Prototyping

includes the availability for being useful in new and ongoing projects by its nature to

be used and developed as is, or by healthcare designers/professionals looking to

identify environmental issues in a specific setting. The flexibility of prototypes

allows for specific scenario testing in details aspects of healthcare design. Next, the

strategy for using baseline modeling is dependent on setup but also in communication

output. The purpose of baseline modeling defined in this research is for the benefit of

making available a sound information basis for future design and including re-design

circumstances. Available information is dependent on the agreement between

healthcare designers and professionals. After the source of data information is

available, any future application of the given information is available for research and

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can be used for credible case studies contributing to formal investigations. Findings

from these strategies reveal that how BIM tools are applied for design investigations

affects the data outcomes. The method of processing a design through BIM should

reflect specific design details which are desired for exploration. The data results are

then clearly supportive of EBD explorations. Referring to Figure 65 shows an

overview relationship diagram of the three BIM strategies along a generic timeline of

a design project.

Figure 65 Diagram of combined BIM strategies.

In addition to BIM supporting EBD, it is also necessary to contribute formal

explorations. While information is made available through BIM, EBD requires

setting up goals and objectives founded on current evidences. BIM is used as a place

for controlled study, analysis and gathering outcomes; is used for hypotheses and

measure. The information gathered using BIM tools would need to shared publically

and submitted for publication in order for it to truly be accepted as EBD. So while,

informally BIM is a large contributor to concept of EBD another level of evaluation

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by academic standards is required before it can be officially be identified as

credible.95 During the BIM process it is important to identify key issues of EBD

which are desired for investigation.

Fundamentally, the learning curve for using BIM tools and applications in

healthcare design is still challenging even though the productivity and quality of this

healthcare renovation project increased remarkably with the suggested methods of

BIM. Currently BIM tools more adequately supports information transfers among

building industry professionals compared to healthcare professionals. Most available

BIM tools are originally created based on design industry standards. These being the

case, healthcare professionals are likely to be less in tune with the methods for

managing information regarding the healthcare environment. Therefore, each

profession must be represented by its own BIM manager to facilitate the information

and guide the BIM process for healthcare design. Perhaps in this early era of

facilitating BIM for healthcare this is a challenge but with the exponential

contribution of information resulting from the relationship of BIM and healthcare the

optimistic probability of BIM tools, strategies and methods will become more

universal between the two industries.

95 Kirk Hamilton, “The four levels of evidence-based practice,” Healthcare Design, no. November (2003).

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9. GLOSSARY

AIA: American Institute of Architects

Baseline Model: [BIM] a post-construction BIM model that was originally developed

during the design of the building as a new construction project or initially integrated

into a project of a building as a renovation/redesign project; contains the previous

design work and provides accurate information regarding the building’s functions and

attributes.

Building Information Modeling (BIM): [process-oriented definition] cooperative

actions between building industry professionals and client user groups, all using

available 3D applications and other digital media for simultaneous and consistent data

sharing in an on-going design project.

BIM tools: Information coordinating systems.

CDC: Center for Disease Control

CFD: Computational Fluid Dynamics

Diagnostic: concerned with diagnosis – process of identifying a medical condition or

disease by its signs, symptoms, and from the results of various procedures.

Evidence-based Design (EBD): using the collected data from credible research,

evaluations and evidence gathered from the operations of the patients, doctors, clients

and other partakers of the health facility become critical factors to make design

decisions.

Evidence-based Medicine (EBM): [formal] the conscientious, explicit, and judicious

use of current best evidence in making decisions about the care of individual patients;

[practice] integrating individual clinical expertise with the best available external

clinical evidence from systematic research.

FGI: Facility Guidelines Institute

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Healthcare module: [BIM] an assembly of organized components, based on

healthcare department needs, contained together and maintaining an independent

nature.

HEPA: high-efficiency particulate air

HIPAA: Health Insurance Portability and Accountability Act

Look-ahead window: allowed preview of the next phase before the phase

commences; allowed view of schedule of activities to remain to be ready for

execution when scheduled; derived from look-ahead scheduling based on an amount

of time in advance that can be accurately forecasted of future events.

MRI: Magnetic Resonance Imaging

NFPA: National Fire Protection Association

Nosocomial: taking place or originating in a hospital

Obstetrics: the branch of medicine that deals with the care of women during

pregnancy, childbirth, and the recuperative period following delivery.

Phase: [BIM] process for providing the ability to forecast the development of on-

going design project and its schedule.

Pediatrics: the medical specialty concerned with the development, care, and treatment

of children from birth through adolescence.

Prototype: [BIM] scaled modeling relationship between category, families and

instances.

Treatment: care provided to improve a situation.

Wayfinding: A word that has gained popularity with the adoption of the Americans

with Disabilities Act (ADA). In its most literal sense, wayfinding is the ability of a

person to find his or her way to a given destination. While the words and graphics on

a building's signs are important to the process, wayfinding also depends on the

information inherent in a building's design.

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10. BIBLIOGRAPHY

Anthony, Robert. “Definition of Evidence-Based Design for Healthcare.” The Center

for Health Design, 2009.

http://www.healthdesign.org/aboutus/mission/EBD_definition.php.

Astedt-Kurki, P., E. Paavilainen, T. Tammentie, and M. Paunonen-Ilmonen.

“Interaction between adult patients’ family members and nursing staff on a

hospital ward.” Scandinavian Journal of Caring Sciences 15, no. 2 (2001):

142-150.

BaHammam, A. “Sleep in acute care units.” Sleep and Breathing 10, no. 1 (2006): 6-

15.

Ballard, Glenn. “Can pull techniques be used in design management?.” Helsinki,

Finland: University of California at Berkeley, 1999.

http://www.leanconstruction.org/pdf/PullinDesign.pdf.

---. “Improving Work Flow Reliability.” In IGLC-7, 275-286. Berkeley, CA:

University of California at Berkeley, 1999.

http://www.leanconstruction.org/pdf/Ballard.pdf.

Barista, Dave. “BIM for Healthcare.” Building Design & Construction, 2007.

http://www.bdcnetwork.com/article/CA6417654.html.

Barlas, D., A. E. Sama, M. F. Ward, and M. L. Lesser. “Comparison of the auditory

and visual privacy of emergency department treatment areas with curtains

versus those with solid walls.” Annals of Emergency Medicine 38, no. 2

(2001): 135-139.

Battisto, Dina, and David Allison. “A Patient Room Prototype: Bridging Design and

Research.” AIA Academy Journal (9, 2008).

http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20080930_battisto2&

dspl=1&article=article.

99

Baxter, Mary. “BIM helps identify mistakes early on in construction at Woodstock,

Ontario hospital.” Daily Commercial News and Construction Record, 2009.

http://www.dcnonl.com/article/id36022.

Bell, Kathy. “Mock-ups: Giving hospital clients the ultimate reality check.”

Healthcare Design, May 1, 2007. http://www.healthcaredesignmagazine.com.

Berg, S. “Impact of reduced reverberation time on sound induced arousals during

sleep.” Sleep 24, no. 3 (2001): 289-292.

Best, M. F., and N. E. Thurston. “Canadian public health nurses’ job satisfaction.”

Public Health Nursing 23, no. 3 (2006): 250-255.

Brandis, S. “A collaborative occupational therapy and nursing approach to falls

prevention in hospital inpatients

.” Journal of Quality in Clinical Practice 19, no. 4 (1999): 215-221.

Buchanan, T. L., K. N. Barker, J. T. Gibson, B. C. Jiang, and R. E. Pearson.

“Illumination and errors in dispensing.” American Journal of Hospital

Pharmacy 48, no. 10 (1991): 2137-2145.

Carmona, Matthew, Sarah Carmona, and Wendy Clarke. A Bibliography of Design

Value for The Commission for Architecture and the Built Environment.

London: University College London - The Bartlett School of Planning, 3,

2003. http://www.cabe.org.uk/files/a-bibliography-of-design-value.pdf.

Cochrane, Archibald. Effectiveness and efficiency: random reflections on health

services. London: Royal Society of Medicine, Press, 2004.

http://www.worldcat.org/oclc/248148013.

Condit, Graham. “Complex projects call for virtual construction.” Seattle Daily

Journal & DJC.COM, no. Health Care Design & Construction - Special

Section (November 16, 2006). http://www.djc.com/news/co/11184025.html.

Davidson, Scott, and Dave Conover. “Application of Building Information Modeling

to Healthcare Facilities” presented at the Healthcare Design 08, Washington

D.C., 2008.

100

Demchak, Greg, Tatjana Dzambazova, and Eddy Krygiel. Introducing Revit

Architecture 2009: BIM for Beginners. 2nd ed. Indianapolis, Indiana: Wiley

Publishing, Inc., 2008.

Douglas, M. K., A. I. Meleis, C. Eribes, and S. Kim. “The work of auxiliary nurses in

Mexico: Stressors, satisfiers and coping strategies.” International Journal of

Nursing Studies 33, no. 5 (1996): 495-505.

Dunston, Phillip, Laura Arns, and James McGlothlin. “An Immersive Virtual Reality

Mock-up for Design Review of Hospital Patient Rooms.” West Lafayette, IN:

Purdue University, 2007.

http://www.envision.purdue.edu/pdfs/papers/01_Dunston_submission_45.pdf.

DFW Consulting, Inc. “Meeting Healthcare Guidelines with CFD Analysis.” Where

Design Meets Excellence, 2006.

http://www.dfwcgi.com/services/Studies/CFDforHealthcare.htm.

Eastman, Chuck, Paul Teicholz, Rafael Sacks, and Kathleen Liston. BIM handbook: a

guide to building information modeling for owners, managers, designers,

engineers, and contractors. Hoboken, NJ: Wiley, John & Sons, Inc., 2008.

Flynn, E. A., K. N. Barker, J. T. Gibson, R. E. Pearson, B. A. Berger, and L. A.

Smith. “Impact of interruptions and distractions on dispensing errors in an

ambulatory care pharmacy.” American Journal of Health Systems Pharmacy

56, no. 13 (1999): 1319-1325.

Gaerig, ed., Chris. “Weill Greenberg Center New York, New York Polshek

Partnership Architects/Ballinger.” Healthcare Design, 2008.

Hagerman, I., G. Rasmanis, V. Blomkvist, R. Ulrich, C. A. Eriksen, and T. Theorell.

“Influence of intensive coronary care acoustics on the quality of care and

physiological state of patients.” International Journal of Cardiology 98, no. 2

(2005): 267-270.

Hamilton, Kirk. “Hypothesis and Measurement: Essential Steps Defining Evidence-

Based Design.” Healthcare Design, no. March (2004).

http://www.healthcaredesignmagazine.com/

101

---. “The four levels of evidence-based practice.” Healthcare Design, no. November

(2003). http://www.healthcaredesignmagazine.com.

Hansen, Bob. “New health care design guidelines emphasize infection control

measures.” Austin Business Journal, no. February (2005).

http://austin.bizjournals.com/austin/stories/2005/02/14/focus5.html.

Harris, P. B., G. McBride, C. Ross, and L. Curtis. “A place to heal: Environmental

sources of satisfaction among hospital patients.” Journal of Applied Social

Psychology 32, no. 6 (2002): 1276-1299.

Harris, D. D., M. M. Shepley, R. D. White, K. J. S. Kolberg, and J. W. Harrell. “The

impact of single family room design on patients and caregivers: Executive

summary.” Journal of Perinatology 26 (2006): s38-s48.

Heimann, PA, and A. Issakov. “The Essential Healthcare Technology Package - A

new WHO tool for planning and managing resources for health interventions.”

WHO Center for Essential Technologies, 2001.

http://www.hab2001.sld.cu/arrepdf/00460.pdf.

Hendrich, A., J. Fay, and A. Sorrells. “Courage to heal: Comprehensive cardiac

critical care.” Healthcare Design, 2002.

Higgs, Steven. “BIM: It's not all just hype.” Healthcare Design, 2008.

http://www.healthcaredesignmagazine.com/

HOK. “The Royal London Hospital - Our BIM approach for the new building”

presented at the AIA TAP BIM Awards 2007, London, 2007.

http://www.bimproducts.net/

Hosking, Sarah, and Liz Haggard. Healing the hospital environment - design,

management and maintenance of healthcare premises. London: E & FN Spon,

1999.

Jonsson, Leslie. “Collaborative design helps hospitals put people first.” A&E

Perspectives 07 Special Section, no. October (2007).

http://djc.com/news/ae/11194201.html.

102

Joseph, A., and R. Ulrich. “Sound control for improved outcomes in healthcare

settings.” The Center for Health Design January, no. 4 (2007).

http://www.premierinc.org/all/safety/topics/construction/downloads/chd-issue-

paper-sound-control.pdf.

Kaldenburg, D. O. “the influence of having a roommate on patient satisfaction.” Press

Ganey Satisfaction Monitor, 1999.

Karro, J., A. W. Dent, and S. Farish. “Patient perceptions of privacy infringements in

an emergency department.” Emergency Medicine Australasia: EMA 17, no. 2

(2005): 117-123.

Kellman, Neil. “History of Health Care Environments.” Journal of Healthcare

Design: Proceedings from the First Symposium on Healthcare Design 1

(1988): 19-27.

Kennedy, Matthew. “Great Expectations: BIM for Healthcare.” The Samborn Report

(Dimensions Newsletter), no. Summer 2008.

http://www.ssoe.com/news/article2.aspx.

Kenyon, Ann, and Molly McFarland. “Medical Simulation: Designing for the

Future?.” AIA Academy Journal, no. September (2008).

http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_20080930_hobbs&ds

pl=1&article=article.

Kistner, U. A., M. R. Keith, K. A. Sergeant, and J. A. Hokanson. “Accuracy of

dispensing in a high-volume, hospital-based outpatient pharmacy.” American

Journal of Hospital Pharmacy 51, no. 22 (1994): 2793-2797.

Kobus, Richard, Ronald Skaggs, Michael Bobrow, Julia Thomas, and Thomas

Payette. Building type basics for healthcare facilities. Canada: John Wiley &

Sons, Inc., 2000.

Laitinen, and Isola. “Promoting participation of informal caregivers in the hospital

care of the elderly patient: Informal caregivers’ perceptions.” Journal of

Advanced Nursing 23, no. 5 (1996): 942-947.

103

Li, Heng, Ting Huang, C.W. Kong, H.L. Guo, Andrew Baldwin, Neo Chan, and

Johnny Wong. “Integrating design and construction through virtual

prototyping.” Automation in Construction, Elsevier 17, no. 8 (11, 2008): 915-

922.

Maione, ed., Orlando. “Open Building: A New Paradigm in Hospital Architecture.”

AIA Academy Journal (October 27, 2004).

http://info.aia.org/journal_aah.cfm?pagename=aah_jrnl_openbuilding_102704

&dspl=1&article=article.

Malenbaum, S., F. J. Keefe, A. C. Williams, R. Ulrich, and T. J. Somers. “Pain in its

environmental context: Implications for designing environments to enhance

pain control.” Pain 134 (2008): 241-244.

Manning, Russell, and John Messner. “Case Studies in BIM Implementation for

Programming of Healthcare Facilities.” ITcon 13 (July 2008): 446-457.

McAllister, Linda. “Who Was Florence Nightingale and Why Is She Important

Today?” Children's Health System, 2007.

http://magnet.chsys.org/default.aspx?id=102.

Miller, George, Christiane Fellbaum, Randee Tengi, Pamela Wakefield, and Helen

Langone. “Princeton University WordNet.” Lexical database. Princeton

University WordNet, 2009. http://wordnet.princeton.edu/.

Mitchell, William. “Artifact Grammars and Architectural Invention.” In Automation

Based Creative Design - research and perspectives, edited by Alexander

Tzonis and Ian White, 139-159. Amsterdam, The Netherlands: Elsevier,

1994.

Miwa, Y., and K. Hanyu. “The effects of interior design on communication and

impressions of a counselor in a counseling room.” Environment and Behavior

38, no. 4 (2006): 484-502.

Mlinek, E. J., and J. Pierce. “Confidentiality and privacy breaches in a university

hospital emergency department.” Academic Emergency Medicine 4, no. 12

(1997): 1142-1146.

104

O’Rourke, K., C. Allgood, J. VanDerslice, and M. A. Hardy. “Job satisfaction among

nursing staff in a military health care facility.” Military Medicine 165, no. 10

(2000): 757-761.

Osler, Sir William. “The Evolution of Modern Medicine.” Electronic Text Center,

1997. http://etext.virginia.edu.

Ozel, Filiz. “Building Information Modeling for Healthcare Facilities.” Microsoft

PowerPoint, Arizona State University - College of Design, May 19, 2008.

http://74.125.155.132/search?q=cache:l4DUm-4SpwMJ:bimhealthcare.com .

Park, Hyoung-June. “Evolution + BIM: the utilization of building information

modeling at an early design stage.” University of Hawaii at Manoa, 2007.

Patel, H.R.H., C.N. Luxman, T.S. Bailey, J.D.M. Brunning, D. Zemmel, L.K. Morrell,

M.S. Nathan, and R.A. Miller. “Outpatient clinic: where is the delay?.”

Journal of the Royal Society of Medicine 95, no. December 2002 (2002): 604-

605.

Philbin, M. K., and L. Gray. “Changing levels of quiet in an intensive care nursery.”

Journal of Perinatology 22, no. 6 (2002): 455-460.

Press Ganey, Inc. “Hospital pulse report: Patient perspectives on American health

care,” 2007. http://www.pressganey.com/galleries/default-

file/Hospital_Pulse_Report_2009.pdf.

Purves, Geoffrey. Healthy living centres: a guide to primary health care design.

Oxford: Architectural Press, 2002.

Revit Architecture. 2010 Imperial Tutorials. San Rafael, CA: Autodesk, 2009.

Sackett, David, William Rosenburg, J. A. Muir Gray, R. Brian Haynes, and W. Scott

Richardson. “Evidence based medicine: what it is and what it isn't.” BMJ

Journals 1996, no. 312. Editorials (January 13,): 71-72.

Southwell, M. T., and G. Wistow. “Sleep in hospitals at night—Are patients’ needs

being met?.” Journal of Advanced Nursing 46, no. 2 (1995): 1101-1109.

105

Stafford, Steve. “Revit OpEd.” Blogger. Room Name - Full or Abbreviation,

December 15, 2008. http://revitoped.blogspot.com/2008/12/room-name-full-

or-abbreviation.html.

Stankos, Mary, and Benyamin Schwarz. “Evidence-Based Design in Healthcare: A

Theoretical Dilemma.” Interdisciplinary Design and Research e-Journal 1,

no. 1. Design and Health (January 2007): 1-15.

Sullivan, C.C. “Integrated BIM and Design Review for Safer, Better Buildings.”

Architectural Record, 2007.

http://continuingeducation.construction.com/article.php?L=19&C=213.

Ulrich, Roger. “View through a window may influence recovery from surgery.”

Science, April 27, 1984.

Ulrich, Roger, Craig Zimring, Xuemei Zhu, Jennifer DuBose, Hyun-Bo Seo, Young-

Seon Choi, Xiaobo Quan, and Anjali Joseph. “A Review of the Research

Literature on Evidence-Based Healthcare Design.” Healthcare Leadership, no.

5. Evidence-Based Design Resources for Healthcare Executives (September

2008): 1-75.

Ulrich, R. S., C. Zimring, X. Quan, and A. Joseph. “The environment’s impact on

stress.” In Improving healthcare with better building design, edited by S.

Marberry, 37-61. Chicago: Health Administration Press, 2006.

Ulrich, R. “Biophilic theory and research for health design.” In Biophilic design:

Theory, science and practice, edited by S. Kellert, J. Heerwagen, and M.

Mador. New York: John Wiley, 2008.

Wakamura, T., and H. Tokura. “Influence of bright light during daytime on sleep

parameters in hospitalized elderly patients.” Journal of Physiological

Anthropology and Applied Human Science 20, no. 6 (2001): 345-351.

Yinnon, A. M., Y. Ilan, B. Tadmor, G. Altarescu, and C. Hershko. “Quality of sleep

in the medical department.” British Journal of Clinical Practice 46, no. 2

(1992): 88-91.